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THE 



DISEASES OF THE EAR, 



THEIR 



DIAGNOSIS AND TREATMENT. 



A TEXT-BOOK OF AURAL SURGERY 



IN THE FORM OF ACADEMICAL LECTURES. 



BY 

Dr. ANTON VOX TROLTSCH, 

Aural Surgeon and Lecturer in the University, in Wurzburg, Bavaria. 



TRANSLATED FROM THE GERMAN AND EDITED BY 

D. B. ST. JOHN ROOSA, M.D. 

ASSISTANT SURGEON TO THE NEW YORK EYE INFIRMARY. 



JUlustrattb fco'tf) ffiSoob £ngrabin<js. 



From the Second, and. last GJ-erinan Edition, 

NEW YORK: 
WILLIAM WOOD & COMPANY, 

61 Walker Street. 
1864. 



nt> 



stfr*~x z/./%4> 




\ 



Vx 



Entered, according to Act of Congress, in the year 1864, bj 
D. B. ST. JOHN ROOSA, 
In the Clerk's Office of the District Court of the United States for the Southern District of 

New York. 



2$-P 



V 



It. Craighead, 

PRINTER, STEREOTYPER, AND ELECTKOTYPER, 

Carton Euilouig, 
81, 88, and 85 Centre Street. 






THIS TRANSLATION 

Is &rj8pKt{uIl5 StDUatib to 

ALFKED C, POST, M,D., 

FBOFESSOB OF 8CBGEBY IN THE UJlVEROITY OF THE CITY OF NEW YOBK, CONSULTING SURGEOft' 
TO TUB IfBW YOBK AND 8T. LUKE'S HOSPITALS, 

WIio, besides his useful labors in the field of General Medicine, has accomplish 
much for Aural Surgery, and to whose qualities as a teacher, surgeon, and a mar. 
this grateful testimony is borne by hia obliged friend and former 

PUPIL. 



TRANSLATOR'S PREFACE. 



The work of presenting to the American Medical public a new 
book on the Diseases of the Ear, was undertaken, because it was 
belie ved that there existed a need for it. 

The most prominent of the Text-Books, which have obtained a 
circulation in the United States, are those of Kraaier, of Berlin, 
Itard and Meniere, of Paris, Toyxbee and Wilde, respectively 
of London and Dublin. The works of the latter named, and espe- 
cially that of Wilde, have found the most favor. 

Wilde's book has been out of print for some time, and there is 
no immediate prospect of a new edition. This is to be regretted, 
for probably no book has done so much for the advancement 
of its object as this production of a distinguished aural and oph- 
thalmic surgeon. 

Toynbee has achieved so much for the only basis of all scientific 
and real progress in aural surgery, pathological anatomy, that we 
can but be grateful to him, although his book, rich in materials, 
seems to lack many of the requirements of a text-book for the 
general practitioner. 

Kramer's work was translated years ago, and we are indebted to 
it as being one of the successful pioneers in the way, now com- 
paratively well trodden. Since then the author's views have been 
very much modified, and the last edition, " Die Ohrenheilkunde 
der Gegemcart, Berlin, 1862," lately translated under the auspices 
of the New Sydenham Society, would hardly be recognized as a 
lineal descendant of the first. This testifies at once to the honesty 
of, and progress in, the author's opinions. 

Through the extreme courtesy of Dr. Kramer, while in Berlin, I 
had the opportunity of seeing a good deal of his large private prac- 
tice, and the pleasure of hearing his peculiar views at some length. 

I also saw somewhat of the practice of Dr. Erhard, Aural Sur- 
geon, and Lecturer in the LTniversity of Berlin, author of " Kli 
nische Otiatrie, Berlin, 1863." This is not the place to enter into 



viii translator's preface. 

any discussion as to the views of these authors, as compared with 
those of Von Troltsch, whose book I am now presenting. The 
fact of the labor I have been at, shows sufficiently my belief in the 
scientific character of the book, and of its adaptability to the wants 
of our profession. 

This work, if indeed the rendering into English shall not have 
proved a failure, will tell its own story, and will stand or fall by 
its own claims. Some few additions made by the translator will be 
found inclosed in parentheses. 

I believe aural surgery to be a comparatively neglected field, 
and my own experience has already been ample enough to show 
that a very much larger number of very chronic cases come to the 
surgeon's eye than in other branches of our art ; consequently, we 
cannot expect the same therapeutic results, as for instance, in 
Ophthalmology, and our reward for labor cannot just now be the 
dazzling one that falls to the lot of successful practitioners in other 
departments ; but if we but succeed in waking up the profession to 
the curability of recent ear cases, and to the fallacy of the idea of out- 
growing these affections, perhaps our work will be done. " Arbores 
seret diligens agricola, quarum adspiciet baccam ipse nunquam." 

Without any responsibility for the truth of Dr. Von Troltsch's 
opinions, his work is presented as one founded on pathological in- 
vestigation, and ample experience, and as containing some views, 
which, so far as I know — and I hope reviewers will note this 
expression — are not to be found in any other book. His method 
of illuminating the external ear, is, I believe, altogether the best in 
use, and one which must commend itself to every one who has 
found the difficulties of the previously known methods. The lec- 
ture on " Purulent Catarrh of the Middle Ear, as occurring in In- 
fants," is one that calls attention in a striking way to some loose 
habits of diagnosis. 

I shall be personally indebted to any gentleman, who has oppor- 
tunities for post-mortem examination of the infant subject, for the 
results of any researches in this direction. I am committed irre- 
vocably to no opinions in the practice of aural surgery, except that 
much may be done to advance its position, and from the oppor- 
tunities afforded in the bi-weekly clinic in the Eye Infirmary in 
this city, now conducted by Dr. Hinton and myself, but which was 
founded by Dr. C. R. Agnew, and successively sustained by his 
colleagues, Drs. Bumstead, Hinton, and Noyes, I hope to be able 
to add a testimony of some value for or against doctrines, which 
are now presented to the profession in these United States. 



IX 

I have in this place to express my obligations to the rare scholar- 
ship of Mr. Alfred A. Post, and to my friend Doctor Henry D. 
Noyes, for some aid in correcting the proofs, and valuable sugges- 
tions of a general character. 

D. B. St. John Roosa. 

New Yobk, Febbuabt, 1864. 



AUTHOR'S PREFACE. 



In undertaking to lay before my professional friends a brief 
text-book, whose aim is to comprise the whole field of Aural sur- 
gery, and be at the same time the result of my personal observa- 
tions and investigations, I scarcely need to apologize for so doing, 
inasmuch as this field occupies a peculiar position in science, and 
original works on the Diseases of the Ear, which are at once purely 
practical and strictly scientific, are still very rare. 

Since it has seemed to me, that a certain brevity, and an empha- 
tic presentation of what -has been already settled and verified in 
distinction from questions still pending, would materially enhance 
the value of a text-book for the practitioner, I have clothed this 
work in an outward form suited to secure this end. 

This will account for the fact, that the work has been divided 
into academical lectures. By this means I have been enabled to 
cut short historical considerations of the subject in hand, with also 
any critical estimate of what has been already accomplished in this 
department, and this much better than would have been possible in 
an ordinary text-book. For the latter circumstance, especially, 
I think I deserve the thanks of my readers. 

I have, moreover, omitted all lengthy explanations, since they 
have been already stated in my " Angewandte Anatomie des 
Ohres, Wiirzbiirg, 1861," Practical Anatomy of the Ear, to 
which work I beg to refer my readers in all questions of an 
anatomical nature. 

A few simple facts, it is true, have been unavoidably repeated, 
since otherwise the clearness of my reasoning would have been 
lessened. I trust, that I may not be found fault with for having 
occasionally quoted, even verbatim,, some of my former mono- 
graphs on sundry topics, as, for example, one on the examination 
and affections of the external ear, the use of the Eustachian 
catheter, perforation of the mastoid process, etc. 

One of our shrewdest men, the aesthetic Vischek, has remarked 



Xll 

that the road to knowledge must always be travelled with 
resignation. This resignation comprises two things, viz. first, 
patience during slow progress in work, and unrestricted severity 
of method ; and, second, the temporary renunciation of the 
whole of truth. It is only by being content to work out and 
investigate some points in the circumference, that we can be 
enabled to look into the centre, and by continually advancing from 
many points at last to penetrate to it. 

The deep wisdom of these remarks is perhaps nowhere illustrat- 
ed with greater force than in explorations into the field of natural 
science, where a genuine enthusiasm for the study itself will more 
frequently find expression in such arduous labors, as are, par 
excellence, the prerogative of the doggedly persistent German 
mind than is allowed in a work of this kind. 

But, if there is anywhere need of such slow, resigned, methodical 
study, in which we penetrate with constant self-criticism, from the 
circumference towards the centre, it is in aural surgery, in the con- 
struction of which a solid foundation is yet to be laid, and for 
which fit material is yet to be procured. Here, each new, well 
chiselled, solid stone is of great and enduring worth, for, from these 
is to be obtained an increasingly stable foundation for a structure 
which shall gradually grow inhabitable. 

It is certainly easier and quicker to rear a wooden structure, 
which with its gorgeous adorning may dazzle the eye, and whose 
color and ornaments may for a time beguile the ignorant into the 
belief that it is of stone, but time continually exercises a just 
criticism, and ere long such a worthless structure will be exposed 
to every gaze, in its real hollowness, while it falls emptily to 
pieces. 

If I have anywhere formed wrong conceptions of facts, or 
explained them incorrectly, I shall be thankful for the information, 
and will gladly avail myself of any better knowledge. 

I may express the hope that I may constantly obtain new fellow 
laborers in aural surgery, which is an equally grateful field in a 
practical and scientific point of view, and that I may have contri- 
buted towards obtaining for this speciality the esteem which is its 
due. 

Anton Von Troltsch. 

Wurzbckg Maj, 1862, 



CONTENTS. 



LECTURE I. 

INTRODUCTORY. 

PAGB 

The Extraordinary Frequency of Diseases of the Ear — Their Great Importance 
as affecting the Individual, his Position in Life, his Longevity, and Intel- 
lectual Development — The Great Prejudice against Aural Practice — Plan 
of this Work, 17 

LECTURE II. 

THE EXAMINATION OF THE AUDITORY CANAL AND MEMBRANA TYMPANI. 

The Diseases of the Auricle — Importance of the Examination of the External 
Ear for Diagnosis, and for General Knowledge of the Parts — The Ear Spe- 
culum — Illumination with the Concave Mirror, as opposed to the Former 
Practised Methods — The Angular Forceps, 25 

LECTURE III. 

THE SECRETIONS OF THE AUDITORY CANAL AND THEIR ANOMALIES, 

Diminished Secretion of Cerumen — Its Traditional Importance — Plugs of Ceru- 
men — Their Gradual Accumulation and Sudden Manifestation — Cases — 
Vertigo and other Symptoms — Prognosis — Treatment, . . . .34 

LECTURE IV. 

SYRINGING THE EAR — FOREIGN BODIES IN THE EAR, 

The Ear Syringe and Method of Use — Some Methods of Removal of Foreign 
Bodies more Dangerous than the Substances themselves — Methods of Pro- 
cedure in Doubtful Cases — Foreign Bodies in the Ear often the Cause of 
Peculiar Reflex Symptoms — Cases, 43 

LECTURE V. 

FURUNCLES IN THE AUDITORY CANAL — BLOOD-LETTING IN EAR DISEASES. 

Symptoms, Course, and Treatment of Furuncle — Place of Blood-letting depend- 
ent upon the Situation of the Affection — Some Rules for the Use of 
Leeches, . . 52 



XIV CONTENTS. 

LECTUKE VI. 

DIFFUSE INFLAMMATION OF THE AUDITORY CANAL, OR OTITIS EXTERNA. 

PAGE 

Periostitis of the Auditory Canal no Independent Process— Different Causes 
of Otitis Externa — The Acute Form, with its Subjective and Objective 
Symptoms — The Chronic Form, 60 

LECTURE VII. 

OTITIS EXTERNA (CONTINUED). NARROWING OF THE AUDITORY CANAL. 

Consequences, Prognosis, Treatment — Vesicants, Cataplasms, and Dropping in 
of Oils to be Avoided — The Slit and Ring Formed Narrowing of the 
Canal — Exostoses and Hyperostoses, 68 

LECTURE VIII. 

INFLAMMATION AND INJURIES OF THE MEMBRANA TYMPANI. 

Affections of the Membrana Tympani very Common, but seldom Occurring 
Alone and Uncomplicated — Acute and Chronic Myringitis — Lacerations 
and Perforations of the Membrane — Several Cases of Fracture of the 
Handle of the Malleus, 77 

LECTURE IX. 

THE APPLICATION OF THE CATHETER TO THE EUSTACHIAN TUBE. 

The History of the Subject — The Common Errors in the Use of the Catheter 
— Method of Introduction — Accidents which may Occur — Spasm of the 
CEsophagus — Emphysema — Haemorrhages — Description of the Catheter, . 85 

LECTURE X. 

THE USE OF THE EUSTACHIAN CATHETER AS A MEANS OF DIAGNOSIS AND CURE. 

Auscultation of the Ear — Otoscope and Air Bath — Substitute for the Catheter 
— Manifold Use of the Catheter in Aural Surgery — Operation of the Air 
Bath — The Catheter as a V ehicle for Introducing Fluid, Gaseous, and Solid 
Bodies into the Middle Ear — Compression Pump 92 

LECTURE XL 

SIMPLE ACUTE AURAL CATARRH. 

Different Forms of Catarrh of the Cavity of the Tympanum — Acute Catarrh, 

its Symptoms and Consequences — Treatment, . . . ... . 105 

LECTURE XII. 

SIMPLE CHRONIC AURAL CATARRH. 

Its Course and Subjective Symptoms — Many Peculiar " Nervous " Symptoms — 
Changes in Appearance and Color of the Membrana Tympani— Its Thick- 
ening — Calcareous Deposits, . .113 



CONTENTS. XV 

LECTURE XIII. 

SIMPLE CHRONIC CATARRH (CONTINUED). 

PAGE 

Morbid Changes in the Fenestra Ovalis and Rotunda — their Effect in Dimi- 
nishing Hearing — Value of Auscultation of the Ear as a Means of Dia- 
gnosis, 118 

LECTURE XIV. 

CHRONIC CATARRH OP THE PHARYNX, AS ACCOMPANYING CHRONIC AURAL CATARRH. 

The Connection between the Ear and the Pharynx, Anatomical and Physiolo- 
gical, made evident by Experiment — Importance of the Muscles of the 
Eustachian Tube — Examination of the Cavity of the Mouth — Rhinoscopy 
— A Case of Pharyngeal Exudation — Symptoms of Chronic Pharyngeal 
Catarrh— Nerve Supply of the Pharynx, 124 

LECTURE XV. 

SIMPLE CHRONIC CATARRH OF THE EAR (CONTINUED). 

Chronic Nasal Catarrh — The Participation therein of the Mastoid Cells and the 
Eustachian Tube, and the Importance of this Prognosis of the various 
Forms of Catarrhal Inflammation, 136 

LECTURE XVI. 

TREATMENT OF CHRONIC CATARRH. 

Local Treatment of the Ear — Air Bath, or Douche — Steam — Mechanical Modes 
of Dilatation — Treatment of the Mucous Membrane of the Pharynx — 
Cauterization — Gargling and its Mechanical Importance — Excision of the 
Tonsils — General Considerations, • 146 

LECTURE XVII. 

ACUTE OTITIS INTERNA, OR ACUTE PURULENT CATARRH. 

General Remarks as to the Different Forms of Aural Catarrh — Symptoms of 
Acute Otitis Interna — Is often Overlooked or not properly Regarded — 
Case of Paracentesis of Membrana Tympani, 160 

LECTURE XVIII. 

PURULENT CATARRH IN CHILDREN. 

As yet only a Pathological Fact — Attempt at an Explanation, and its Value 

for the Aural Practice, 167 



LECTURE XIX. 

CHRONIC PURULENT AURAL CATARRH, OR CHRONIC OTITIS INTERNA. 

Subjective and Objective Symptoms— Treatment— Perforation of the Mem- 
brana Tympani ; its Importance to the Patient, and its Possible Healing — 
The Artificial Membrana Tympani, 179 



X V1 CONTENTS. 

LECTURE XX. 

AURAL POLYPI • A FULL CONSIDERATION OF THE IMPORTANCE OF DISCHARGES 

FROM THE EAR. 

PAGR 

Origin and Structure of Aural Polypi — Treatment — Otorrhoea, considered with 
Reference to its Influence on the Circulatory System — Emboli — Septic 
Infection — Metastasis — Caries of the Temporal Bone, with its Conse- 
quences — Phlebitis — Abscess of the Brain — Meningitis Purulenta, . .190 

LECTURE XXI. 

FURTHER CONSEQUENCES OF OTORRHEA ; PROGNOSIS AND TREATMENT. 

Facial Paralysis — Tubercle and Cholesteatoma of the Petrous Portion of the 
Temporal Bone — The Uncertain Prognosis and Treatment — The Incision 
behind the Ear, and Perforation of the Mastoid Process — Prejudice against 
Local Treatment (A Case reported by Dr. C. R. Agnew), . . . 204 

LECTURE XXII. 

NERVOUS DEAFNESS. 

The "Want of Anatomical and Clinical Proofs of this Affection — A Case of 
Nervous Deafness in an Artillerist — The Disease of the Semicircular 
Canals, with Cerebral Symptoms — According to Meniere, . . .217 

LECTURE XXIII. 

Nervous Earache — Deafmutism — The Application of Electricity in the Treat- 
ment of the Ear — Hearing Contrivances, or Ear-Trumpets, . . , 228 

LECTURE XXT7. 

METHOD OF EXAMINING THE AMOUNT OF HEARING. 

Hearing a "Watch, and Understanding Conversation, as Compared with each 
other — Watching the Mouth of the Speaker by a Deaf Person — How a 
Measurer of the Hearing Power should be made — Conduction of Sounds 
by the Bones — Better Hearing in the midst of Noise — Extremely Acute 
Hearing, or Fineness of Hearing, 237 

LECTURE XXY. 

TINNITUS AURIUM. 

Examination of Patients — Conclusion, 24.5 



DISEASES OE THE EAR. 



LECTURE I. 



INTRODUCTORY. 



The Extraordinary Frequency of Diseases of the Ear— * Their 
Great Importance as affecting the Individual, in his Position in 
Life, his Longevity, and Intellectual Development — TJie Great 
Prejudice against the Aural Practice — What must happen before 
Progress is made — Plan of this Work. 

Gentlemen — At the time when you expressed the wish that I 
would give a series of lectures on Diseases of the Ear, you de- 
sired that I should not omit even the most insignificant details 
of this branch of science, assigning as a reason, that before this 
you had had no opportunity at all, except the most superficial, 
to see or learn what may happen to the ear. This ought to 
surprise me somewhat, when I consider that a number of you 
have passed the State examination, and as young Doctors will 
soon begin the practical course, while the remainder are at least 
in your last session. Moreover, you have pursued your studies 
not only in WtLrzbnrg, but also in other of the most renowned 
of our medical schools. Yet I know too well from my own 
experience, how true this may be. During the time of my 
student life (184 7-1856), there was, in the schools of Germany 
and Austria, which I attended, and these were all the most cele- 
brated, absolutely nothing to see in this province. I also visited, 
mainly out of great interest in this branch of science, the 
medical schools of Great Britain and France. I found, how- 
ever, nowhere the opportunity of a thorough theoretical and 
practical studv of diseases of the ear, although in certain 

2 



18 



INTRODUCTORY. 



places, for instance, at Wilde's in Dublin, and Toynbee's in Lon- 
don, the opportunity was given for some valuable observations 
and to collect many details of practice of the highest value. 
This absence of opportunity for learning, in one entire division 
of medical knowledge, has something uncommonly startling, 
and recalls the fact right lustily to our consciousness, that 
there are few men who, only in a moderate degree, pay any 
attention to diseases of the ear. While the number of Oculists 
in Germany already begins to be Legion, and we have at least 
one in every school of high grade, and in every city not too 
small, the number of Aurists, who devote themselves to the 
subject in any particular manner, worth naming, in a literary 
or practical way, is still extraordinarily small. Whence comes 
this remarkable and wrong condition of things ? Whence 
comes it that so few take any interest in this department ? 
Whence is it, in fine, that the interest in these affections is 
so circumscribed, and the consequent sum of the knowledge of 
diseases of the ear, when we consider how the science of heal- 
ing, on the whole, is advanced, is so little. We cannot get out 
of the way of this question. It occurs to every one, even in 
the most superficial consideration of the subject, and I shall 
deem it my duty to talk with you, concerning this query. In 
this manner I think we shall be able to come to our oppo- 
site standpoint of observation, and perhaps I may be able to 
tell the origin of many errors and prejudices, what their 
course is, and so expose them, that you shall not be deceived 
by them. Wherein, then, does it lie, that there is so little inte- 
rest in this direction of our field of knowledge ? " It is not 
worth the trouble, to give one's self up to the investigation of 
ear diseases," says one, " because there are so few cases." This 
now is a great error, a prodigious error ; there are wonderfully 
many ear patients, yea even, when we examine the matter 
closely, there are more ear than eye patients. We remem- 
ber that nearly all old persons, over fifty or sixty years, 
no longer hear perfectly well, many of them badly, a fact to 
which we have become so accustomed that in social life we 
scarcely notice it, being almost inclined to believe these symp- 
toms to be physiological. We should also remember that in 
childhood discharges from the ear are by no means seldom, 
and that earache is so common with children that the greater 



INTRODUCTORY. 19 

Dumber of them suffer from it. But diseases of the ear occur 
very often in middle life. There are, it is true, very few com- 
pletely deaf persons in this time of life, yet the number of 
those whose hearing power stands somewhat under normal is 
very considerable, and a greater number of persons in this 
period, in exacter observation, notice a diminution of the 
hearing if only on one side. But look only in our own circles, 
and see how few can only auscultate with one ear, " from 
habit " as they themselves perhaps think ; in truth, perhaps, be- 
cause they only hear distinctly with one ear. In ordinary life 
the demands made upon our hearing power are so moderate 
and undefined, that the departure from good hearing power 
must be quite considerable, if one's enjoyment for social life be 
disturbed. A great number of persons are hard of hearing on 
one side only, and their affection is not only unknown to their 
associates, but also to themselves. 

Although it is hard to get at the exact state of the case, yet 
I think I shall say too little, rather than too much, when I 
consider that even in the middle period of life (20-40), of three 
persons, certainly one no longer hears well and normally with 
one ear at least. You will experience it in your own practice. In 
the beginning you will hear nothing of ear patients, until the 
people find out by some lucky chance that an aurist lives 
among them. Then suddenly a mass of ear patients will come 
to view, partly in persons whom you have already known, 
without any idea that you would be called upon to treat them 
with ear affections. We can generally see the complaint of 
eye patients. Ear diseases, however, are different, there is 
nothing striking in their complaint ; and with or without the 
intention of the patient, it is commonly concealed. Believe 
me, there is an immense number of ear patients, and there 
would be still more of them known, if there were more 
surgeons who would take the care of them; for up to this day, 
many of the cases in the beginning are not observed, yes even, 
intentionally neglected and concealed. It cannot then, gentle- 
men, be ascribed to the absence of material, that physicians 
trouble themselves so little with ear diseases. 

Perhaps the ear patients are less disturbed by their troubles, 
and consequently demand less interest on the part of the 
physician. Kow, I do not wish to awaken the very old, and 



20 INTRODUCTOKY. 

in my opinion, very profitless strife, as to whether it is better 
to be deaf or blind ; but it is certain that a noticeable loss of 
hearing power not only lessens the highest grade of life enjoy- 
ment, since it renders troublesome that noblest part of our 
life, — life among our fellows ; but also, that not a few, through 
such a misfortune, are prevented from fully carrying on their 
business pursuit, certainly their power of doing so becomes 
somewhat limited. Think only, of the position of an army 
officer, teacher or public official, who has become hard of 
hearing. Often enough must such a one on this account give up 
his office ; at least, an advancement in it will be much hindered. 
Again, a considerable loss of hearing power will prevent the 
merchant and mechanic to a considerable degree, in the pursuit 
of his avocations. But hardness of hearing more seriously 
affects the child, in preventing its full development. If it be 
of high degree, then the child, who does not hear the language, 
does not learn to speak at all, or if older, forgets the sound of 
the words, and in either case becomes completely dumb as 
well as deaf. I do not need to tell you that a deaf and dumb 
person, even under the best method of instruction, can never 
be made an equal, useful member of society. The lower 
grades of hardness of hearing also, if occurring in the early 
period of development, retain their influence upon the whole 
of the later existence. ~Not only that such children are with 
difficulty accustomed to concentrate their attention, that they 
remain inattentive and volatile, but also the absence of distinct 
intellectual impressions, which are mostly made through the 
•ear, will never render a clear thinking power possible, a 
working together of the intellectual and physical powers. 
People who from early life have been somewhat hard of hear- 
ing, have generally something in their nature a little foggy, 
are uncertain, and weak in commercial pursuits, illogical and 
superfluous in thought and speech, abrupt and out of character 
in their answers. 

" Nil in intellects, quod non antea fuerit hi sensu" said 
Aristotle. If the physical appreciations are obscure, half way, 
and undecided, then the whole intellectual existence and 
character bears this stamp. In which way is the most of 
the educational material furnished to the child? Doubtless 
through the ear. 



INTRODUCTORY. 21 

But in another view of the case, affections of the ear belong 
to a class of very disturbing complaints. Eemember the subjec- 
tive symptoms, the " noises in the ear" occurring in so many 
ear patients, in varied forms, and which to many are more trouble- 
some than the deafness, and which cause such a sense-destroying 
effect, that it brings the sufferers almost on the borders of 
insanity. I call to your memory the dreadful pain which is 
connected with many inflammations of the ear, and which some- 
times causes even the stolidest and most enduring men to 
shriek with pain. Still more, diseases of the ear, especially 
those connected with discharges, often end in death. Long 
continued and neglected diseases of the ear develop them- 
selves, sometimes as abscesses of the brain, meningitis, pycemia, 
as each one of you has seen in the Medical Clinic. 

Thus we see that Diseases of the Ear arrange themselves 
among those classes of affections which exert the deepest and 
most energetic influence, and that this influence extends even 
to the intellectual development, and upon the lifetime of the 
individual. Certainly they have a greater influence in these 
respects than diseases of the eye. It cannot be their harmless- 
ness which causes physicians to neglect them. 

But we are told, " There can be nothing done for diseases 
of the ear." Shall we examine and see why there is nothing 
to be done for diseases of the car ? Perhaps the tissues of the 
ear, and therewith its lesions, differ from those wo know in 
other parts of the human body, and are therefore fully removed 
from our medical appreciation and understanding. 

The external auditory canal is covered with a continuation 
of the skin covering the body. The Drum of the ear, or 
Membrana tympani, consists of fibrous tissue ; the covering of 
the middle ear, the Eustachian tube, the mastoid process, is 
formed from a mucous membrane, the continuation of the 
mucous membrane of the mouth. Finally, the internal ear, 
the labyrinth, consists as to its covered portion partly of 
connective tissue, partly of nerve fibres. The groundwork of 
the whole part consists of bone, partly dense, impermeable, 
partly porous. We find then, in the auditory canal, only the 
common tissue everywhere continued, and we must therefore 
consider it as having part in the pathological processes, every- 
where occurring in other parts of the body. But perhaps the 



22 INTRODUCTORY. 

parts lie so concealed and obscure, that we cannot recognise 
their affections, cannot make a diagnosis. This is again not 
the case. As we will later on more clearly see, the external 
auditory canal, and the membrana tympani, lie directly open 
to the view of the surgeon. The condition of the Eustachian 
tube, and of the cavity of the tympanum, we are able to know 
partly through direct physical perceptions, and partly from 
deductions from the condition of the membrana tympani, and 
the degree of the loss of function. The condition of the inter- 
nal ear, we are able entirely to know, of course in no other 
way, than by exclusion or from probability. However, this 
is often the case in nervous diseases, and according to all the 
later observations this class of affections of the ear is quite 
rare. 

We are able then to diagnosticate diseases of the ear, quite 
as well as many other classes of disease ; certainly better than 
diseases of the kidneys, liver, or spleen, which, however, no one 
to whom they come would designate as affections in which 
there is nothing to be done. So much as refers to the diagno- 
sis, refers also to the therapeutics, as has been seen, and which 
we will hereafter speak of in detail. !Not considering that 
here, as in other cases, constitutional remedies are at our ser- 
vice, we know that the external surface of the membrana 
tympani and auditory canal are entirely accessible to local 
treatment, and we are enabled through the Eustachian tube, in 
various ways, to affect the middle ear. 

If then we see that the number of ear patients is very large, 
and the consequences of ear diseases in every respect very 
important, since they extend an influence upon the life, happi- 
ness, and social position of the adult, but also on the intellectual 
development of the child, yea, they even often bring the life 
in danger; furthermore when we consider that we can find 
here no reason why the efforts of the physician cannot be as 
successful as in other branches of disease, considering all these 
things, it is peculiarly hard to understand why this branch of 
medical science has been so little attended to, in general 
entirely neglected. 'The more exactly we observe the thing, 
the more fails every fitting answer to the question, and we 
must consider the small estimation and want of interest with 
which even many of the most intelligent physicians consider 



INTRODUCTORY. 23 

the whole province as entirely groundless, or based upon a 
wholly untenable position. It comes from traditional opinion, 
one determined from false reasoning, and a want of under- 
standing of the subject, that affections of the ear have been disre- 
garded, that very few physicians have attended to them, and 
finally that the scientific treatment of diseases of the ear, in its 
development, is far behind other specialities. This has not 
come to be the case, because there is little to be done ; but 
because little has been done. Up to the present time scarcely a 
beginning has been made in the laying down of the ground 
principles of the practice, as has been effected in the other 
departments of exact medicine. But you ask — Have there not 
been attempts already made to 6how that it is true that 
" nothing can be done for diseases of the ear ?" It is true, it 
has been said here and there, wherein lay the exceptional 
position of this branch of science, and why the treatment 
remains so far behind, and why this will always remain so. 
In my opinion, all these reasons are far behind the times, 
and we should wait with such decisions, which deny to 
medical science any advance in a certain direction, until a 
greater number of abler and educated men have undertaken 
the study of this science, and its basis, as an earnest lifework, and 
until at least the greater number of physicians have become 
acquainted with the necessary assisting remedies of the 
specialty. Nowhere has so little been done in medicine as 
exactly here, and therein it appears to me to lie, that so little 
progress has been made. 

Before all things, we must labor in three directions, before 
that anything shall be accomplished in the Diagnosis and 
Treatment of Diseases of the Ear, if the science shall have any 
worth. 

First. The pathological anatomy must receive more considera- 
tion, in order that we understand better the diseases which 
precede, and which lie at the basis of all functional disturbance. 

Second. We must further, through pains-taking and careful 
physiological experiment, be in the position to know the parts 
of the ear in their relative importance in a normal as well as 
pathological condition. 

Finally. We must seize and employ all exact methods of 
examination of the ear, so that each one may easily come to a 



2-i INTRODUCTORY. 

right understanding of its affections. We shall see in these 
several directions how much is still wanting, and it will be 
plain enough to appreciate in the course of our study together. 
After these foregoing explanations more of a general nature, 
I have still to say, what plan I shall follow, and what you may 
expect from our coming together. I will endeavor to set forth 
the various affections which I recognise in the organ of hearing 
in their anatomical succession, picture these in their symptoms, 
and make you acquainted with their treatment. It will please 
me very much, if I shall succeed in exciting in you an 
abiding interest in the generally misunderstood, because 
unknown " Diseases of the Ear," and I know with certainty 
that if I shall, you will thereby be much more useful in your 
future life among men. 



LECTURE II. 

THE EXAMINATION OF THE AUDITORY CANAL AND MEMBRANA 

TYMPANI. 

The Diseases of the Cartilage of the Ear. — Importance of the 
Examination of the External Ear for Diagnosis, and for gene- 
ral knowledge of the parts. — The Ear Speculum. — The lllwnina- 
tion icith-the Concave Mirror as opposed to the former practised 
methods. — The Angular Forceps. 

Gentlemen — We turn to-day to the diseases of the outer ear, 
under which name we include the auricle, and external 
auditory passage. The diseases of the auricle of the ear can 
be rightly passed by, since it is seldom affected alone, and if 
there are also affections of the surrounding parts, the appear- 
ances are in no way particularly marked. Before we, how- 
ever, pass on to the diseases of the deeper lying parts, we 
must look at the means employed in diagnosticating them ; we 
have then to consider the examination of the external auditory 
canal and the membrana tympani. It is not possible to make 
any correct diagnosis in diseases of the ear, without first being 
able to examine these two parts well. For a thorough inspec- 
tion of these not only enables us to state their condition, but 
it also affords, at the same time, an explanation in respect to 
a number of deeper affections. The membrana tympani forms 
the partition wall between the auditory canal, and cavity of 
the tympanum, or middle ear, and the inner side of it contains 
a coating of the mucous membrane of the middle ear, and thus 
takes part in all the diseases of the cavity, and its coverings. 
Then the pathological changes of the mucous membrane 
covering the tympanum exert an influence on this membrane ; 
so that we can, from the knowledge of the condition of the one, 
safely diagnosticate as to the other. 



26 EXAMINATION OF THE AUDITORY CANAL. 

Hence is it, that the examination of the auditory canal, and 
with it of the membrana tympani, constitute themselves our 
best diagnostic appliances. If I were to say to you, that in 
accordance with my experience, the greater number of 
surgeons are not in a position to appreciate what is to be seen 
in the outer ear, much less critically examine it, you will fully 
understand why the present position of the ear practice is so 
little satisfactory. It is an undeniable fact, that the greater 
number of practitioners cannot at all examine the ear, and 
scarcely is a secret made of such ignorance. This fact is of 
uncommonly vast importance. Yes, indeed, the evil position, 
on which the investigation of ear diseases to-day rests, may be 
traced back to this. Whoever does not know how to examine 
the ear, should not attempt a diagnosis of its affections ; if he 
does not know what is the matter with the patient, he has no 
conception of what is to be done against the disease. 

Each attempt at treatment, therefore, must remain without 
effect, unless a lucky chance should help. It is an old and 
psychological, and very easily understood adage, that we 
practise willingly and highly esteem what we understand, and 
feel ourselves safe in ; and to reverse it, what we imperfectly 
understand, and where we are not at home, we do not like, and 
if possible push aside. 

Some pains-taking physicians have openly confessed, that 
it is against their conscience to prescribe for an ear patient, for 
they cannot properly examine him, and they are ashamed to 
attempt to do anything for a patient without knowing what 
the disease is. Almost every physician is glad when he has 
got rid of an ear patient. The reason that physicians in 
general so little esteem the treatment in diseases of the ear, 
and assert this so openly at each opportunity, is because they 
think in this manner to be able to soften and palliate, before 
the world and themselves, the burdensome feeling of their own 
bad judgment. Very naturally, the very poor prospect for 
aid from physicians, was long since known to the lay public. 
]S"ever do patients seek a physician so late as in ear diseases, 
and never do they so commonly try advertised books and 
remedies. Patients feel themselves without help from this 
quarter, where in other cases they find it, therefore quackery 
has a fair field. Because physicians have so little knowledge 



EXAMINATION OF THE AUDITORY CANAL, 27 

of these affections, windy and superficial babblings can be palmed 
off as, learned labors, and medical humbugs and phantasies 
draw out an existence on this territory. 

You see, gentlemen, that we always come in a dreary circle, 
again to our starting point, viz. the fact that the profession, up 
to the present time, have not understood how to examine the 
ear ; such being the case, we must find in this fact, a reasonable 
ground for the general unsatisfactory condition of the treat- 
ment of ear affections. What then is the ground of this 
improper position I Is the examination of the auditory canal 
and tympanum so particularly difficult, or were the previous 
methods not good and capable of being generally practised ? 
In my opinion it is not in the difficulty, but in the method. 
That the previous ones are not good and practical in the full 
sense of the word, is sufficiently proved, from the fact that 
even now 60 few physicians can examine the ear. A really 
good method would have long since broken the way, and 
things for years past would have stood in a different position 
from that in which they unfortunately now are. The fact, that 
a great number of easily distinguished and very common 
changes and abnormal appearances in this membrane, concern- 
ing which we will speak more fully, have been entirely 
misunderstood by aurists, speaks still more of the uselessness of 
the previous methods. The errors can only be ascribed to 
the manner of examining. We turn now directly to the 
subject. 

Without any assisting means, we can see only the opening of 
the auditory canal. If we pull the tragus a little forward, 
while at the same time we draw the concha backward, we 
widen the hole of entrance, and we are able to examine the 
first part of the passage. We are not able, in this manner, to 
look any deeper unless the canal is abnormally wide, which is 
very seldom the case. Generally, the auditory canal is too 
narrow to allow sufficient light to fall upon the deeper part 
and upon the membrana tympani ; the canal does not run in a 
straight line, but it is angularly curved, and there are also little 
hairs in the way, which grow from the side of the bony part. 
If we wish to see the tympanum, the deepest lying part, fully 
and exactly, we must remove all these hindrances, in a word 
we must sufficiently illuminate the background, change the 



28 EXAMINATION OF THE AUDITORY CANAL. 

crooked line of the canal to a straight one, and push the little 
hairs to one side. 

All these requirements, we can in the simplest and best way 
attain, if we place a coniform tube in the passage r " ear specu- 
lum," and when prevented from the use of sunlight, bj means 
of a mirror, see into the deepest part. These tubular, unopen- 
ing specula, are to be preferred to Itard's or Kramer's ear 
specula, almost generally used in Germany. These latter 
are much larger and clumsier, not so convenient or easily 
adapted to their purpose. In general, all the widening of the 
bony canal that is necessary, can be accomplished from the 
coniform specula, and we have no use for the dilatation of an 
instrument, which, if pressed open while in the ear, easily 
causes pain. The use of this valvular speculum will also be 
sometimes contra-indicated because the little hairs and the 
epidermis are apt to protrude through the sides, and obstruct 
the view. This (Kramer's valvular-handled instrument) we 
must always hold as long as the examination lasts, while specu- 
la of the other kind, of the proper size, and properly placed ? 
generally remain in position, while the hand is free for 
other manipulations. 

Wilde's ear specula, which I generally use, are silver tubes, 
or blunted cones. Three different sizes are generally used ? 
according to the size of the canal to be examined ; these rest in 
each other, and can be conveniently carried in the vest pocket. 
Each speculum is about one and a half inches long, the greater 
opening three quarters of an inch diameter, the-lesser, four lines. 
They should be very thinly and lightly constructed, and the 
lesser opening well rounded off, so that in placing it in the 
auditory canal no abrasion or wound may be made. It is a 
matter of less importance, whether they are polished exter- 
nally or more or less darkened. In order to use these, the auri- 
cle is drawn somewhat backwards and upwards, and after the 
curvature of the canal is overcome, with the other hand the 
speculum, by a gentle motion, is placed so far in, as is possible 
without violence. When the instrument is in place the second 
hand is unnecessary, and the thumb, while the index and mid- 
dle finger hold the upper part of the cartilage, is turned under 
the outer opening of the speculum. 

In this manner, the speculum and auditory canal are held 



Fie. L 



EXAMINATION" OF THE AUDITORY CANAL. 29 

in the proper manner, and can both he changed to different 

•directions, in order to bring the mem- ^-^ 

brana tympani and the different parts |ffl 

of the auditory canal, on all sides, into I ! 1 \ ^j 

the field of vision. Beginners are apt to if IB 

leave the ear to itself and hold the spe- ■ IB s~\ 

-culum alone; in this manner, we can /f fjfil ^J 

easily press against the covering of the ml §B 

auditory canal, occasion pain, and pre- mil I | ||||B| O 

vent full use of the mobility of the spe- J^h3^L 

culum. If we then draw the speculum ^B^ 

slowly out, we can see each part of the 

•canal exactly. 

Of greater importance, is the question how can we best 
illuminate the auditory canal and membrana tympani! The 
valvular speculum is less convenient than the tubular one 
which I have described, yet we can well and thoroughly 
examine the ear with it, even if it be a little troublesome. It 
is not so, however, with the former methods of ill am nulling die 
ear, which prove themselves wholly insufficient. Until now, 
we have been in the habit of using only sunlight or bright 
daylight, falling through a window, into the canal, and down to 
its bottom. This method, still employed more than any other, 
is wholly impossible when there happens to be no sunlight. 

Do not accustom yourself always to use it, even when it is 
to be obtained, only in certain cases. We cannot always see 
distinctly enough with it ; moreover, it is not convenient. We 
learn from our daily experience with sunlight illumination, 
that it is a great deal too glaring and blinding in order to 
serve us where small and indistinct changes of form and color 
exist. It is an optical fact that direct sunlight, in general, is 
not so good for use, as broken and diffused light. 

We could examine the ear better with simple immediate day- 
light, if there were not necessary such a number of favorable 
circumstances, working with us to secure the desired end. If 
we wish to make use of daylight, in examining a patient, he 
should be brought to the window. Bedridden patients in 
most cases cannot be thus taken. The window must be free 
from curtains, blinds, etc. If it does not look on the open sky, 
or opposite a house on which the sun shines, the light will not 



30* EXAMINATION OF THE AUDITORY CANAL. 

be enough to illuminate the deeply lying parts of the ear. 
The position of the surgeon is a very bad one in this method 
of examination. He must stand between the light and the 
patient, and thus he easily makes a shadow with his head. 
This will more commonly occur when the surgeon is far- 
sighted. Indeed when little practice has been had, this making a 
shadow with the head of the surgeon, is very troublesome, pre- 
cluding, as it does, the possibility of examining the drum 
of the ear. Moreover, since, for the foregoing reasons, the 
head of the surgeon cannot be very near the ear, minute 
changes, especially in the membrana tympani, may pass 
unnoticed even to the sharp-sighted ; thus the method must 
always be confined to coarse distinctions. More than all, we 
cannot always have bright daylight at our service. In a 
climate so rich in clouds and rain as that of Germany and 
England, we must often wait weeks to find daylight enough 
to make an examination of the ear. This last is an evil posi- 
tion, which demands the introduction of another method ; and 
one that does not depend upon weather. For how can we 
speak of a progressive, exact distinction and examination of a 
single case, if we cannot daily, and at any hour in the day, 
have at hand the means of such an examination ? This great 
deficiency, the dependence of the illumination and examina- 
tion upon the weather, upon the kindness of the skies, was 
naturally felt long ago, and it was attempted to help the 
matter by means of an apparatus furnishing artificial light. 

The first attempts were made in the middle of the last 
century by an English army surgeon, Archibald Cleland. The 
surgeon held in his hand a large convex lens, the centre of 
which is opposite to a wax light, so that the united rays of 
light are thrown through the lens into the auditory canal. 

All the illuminating apparatus which have been produced 
since this, possess no very great improvements on this, for its 
time, a very great advance. Instead of the convex lens, a 
concave one is used ; instead of wax light, gas, oil, etc.* 

Some of these appliances are exceedingly bunglingly con- 
trived, and there are many of them which are still being 

* For a more minute account of these appliances, see my brochure, '-The 
Examinatioa of the Auditory Canal and Membrana Tympani." " Die Untersucliung 
des Gehorgangs und Trommelfeils." Berlin. 1860. 



EXAMINATION OF THE AUDITORY CANAL. 31 

presented, which speak more for the ingenuity of the invention 
than for their practical worth. Those consisting of an artificial 
light, passed through a hole in a concave mirror, are still in 
constant use among many aurists. All these aids to examina- 
tion have to do with an artificial colored light, which adds 
something foreign to the color of the parts, and does not allow 
the exact condition and color to appear. 

But it is not necessary to have any artificial light, or compli- 
cated contrivances, in order to always obtain a strong, deeply 
reaching illumination of the canal and membrane. If we take 
a sufficiently large and strong concave mirror, and throw by 
means of it a strong stream of ordinary daylight upon the ear, 
we can see the parts clearly to the minutest portion, which with 
the naked eye is impossible, and this method sweeps away all 
the evils attending the other ones. The mirror must be of 5-6" 
focal distance, and not less than 2$ to three inches in diame- 
ter. Metal mirrors are not so good as glass, and it is most 
convenient if they are perforated in the center, or the quick- 
silver covering can be removed at this point. The mirror of 
the ophthalmoscope is not adapted for this purpose, being too 
small and having too small a focal distance, and consequently 
we cannot detect minute changes. Coarser distinctions, such 
as if the membrana tympani is wholly or partially covered, 
grey or red, if the canal be stopped or free, we can generally 
well enough ascertain with the small mirror. 

In certain cases, e.g. during operations, or the administra- 
tion of an air bath, I fasten the mirror to the forehead, as in 
the use of the Laryngoscope. The use of the reflector enables 
you to turn the ear away from the window, the patient being 
between the window and the surgeon. We can examine 
adults most easily in the standing position; in the case ot 
children the patient sits or places the little patient on a stool, 
so as to be parallel with him. 

Since the ear lies in the middle of the head, we do well to 
lower it a little, or place it slightly to one side in order that no 
portion of the mirror may be shadowed. We very soon learn 
how to place the mirror and the patient, so that we have the 
very best point of illumination. If we give the mirror a slight 
motion to one side or the other we quickly find the best rela- 
tive position of the deepest part. White or light grey clouds 



32 EXAMINATION OF THE AUDITORY CANAL. 

afford here as with the microscope the best light. Sunlight 
thrown directly into the ear is too dazzling, and excites at 
the same time a distinct feeling of heat in the membrana 
tympani. If we find the sunlight, immediately opposite this, 
we turn the patient away to the other parts of the sky. 

Experience will teach us, that this method of examination 
is preferable to all others, and that its advantages in opposition 
1 to those formerly practised are very great. The colorings of 
the part are not changed as with an artificial light ; but are 
given back distinctly and truly. The necessary appliances* 
are simple, not costly, and portable. The greatest advantage, 
of this method of illumination, however, is that it may 
be practised in all kinds of weather, when the patient lies in 
bed (if necessary with a candle), and we are not obliged to turn 
the patient to a window if it be too far off, and a light colored 
wall be near. 

Furthermore, the examination of the ear in this manner is 
easy and convenient, there is no danger of making a shadow 
with our heads, and we can yet come very near to the patient, 
and see clearly the smallest and finest distinctions in form and 
color. It is by no means difficult to learn this method of 
examination, and it has proved itself a good and practical 
one. (See Frontispiece.) 

Another instrument is also necessary, in the examination of 
the ear, to remove scales of epidermis, cerumen, and similar 
little hindrances which, at the insertion or moving of the 
speculum, lie before the opening, and thus prevent a full view. 
We use for this purpose an angular forceps, with which we 
can take foreign bodies out of the canal, without putting our 
head in the light. 

Since we may easily do damage to the walls of the canal, we 
must be careful not to use any force, and guard the patient 
against moving his head, during the operation ; you will' under- 
stand that no such attempt is to be made, unless we have the 
light under our control, and can see what we are about. 

If there be any discharging secretion in the canal, or 
on the membrane, it may be removed by the use of a camel's 
hair pencil, introduced on the forceps. The different specula 
of Wilde, Toynbee, Gruber, Arlt, do not differ essentially, and 

* They may be obtained at the surgical instrument manufacturers in New York. 



EXAMINATION OF THE AUDITORY CANAL. 



33 



are all to be preferred to the valvular. This last named was 
discovered in the seventeenth century by Fabrizius von Hilden, 

and is now known generally as 
Itard's or Kramer's speculum. 

The above described method of 
illumination, with the concave mir- 
ror, I claim for myself, as not having 
heard anything of it from another, 
and I showed it in December, 1855, 
in the Union of German physicians, 
assembled in Paris. After this I 
learned that a similar method had 
been proposed before, by a physi- 
cian from Westphalia, Dr. Hoffman, 
in Burgsteinfuhrt, in 1841, who 
recommended the use of a centrally 
perforated mirror, with which to 
throw snn or daylight into the ear, 
and thus to illuminate the parts. 
This suggestion of Hoffmann's does 
not seem, however, to have made 
any deep or lasting impression, nor 
to have been adopted by any of 
the known Aurists. It received so 
little attention that the most of the 
books on diseases of the ear make 




no 



mention of it ; while I believe 



Fig. 2. 



that this method of illumination is 
the only one which always and 
under all circumstances can be prac- 
tised, with which alone a minute 
and careful examination can be made, and that the introduc- 
tion of this method into general practice would make it possible 
that a more successful era of aural practice should be entered 
upon. 



LECTUEE III. 



THE SECRETIONS OF THE AUDITORY CANAL, AND THEIR ANOMALIES. 

Diminished Secretion of Cerumen. — Its Traditionallmportance. — 
Plugs of Cerumen. — Their Gradual Accumulation and Sudden 
Manifestation. — Vertigo and other Symptoms. — Cases. — Prog- 
nosis and Treatment. 

Gentlemen — In treating of the diseases of the external auditory 
canal, we have to speak, first, of its secretions and their anoma- 
lies. In the same way that tears are by no means only a secre- 
tory product of the lachrymal gland, but also, a product of the 
mucous membrane and Meibomian glands, so is it with the 
secretions of the auditory canal, which we call " ear wax." This 
substance is furnished not only by the proper ceruminous glands 
of the ear, which are very similar to the sudoriferous glands of 
the outer skin, but also by the other parts, in the skin of the 
canal, which also have secreting properties. The numerous se- 
baceous glands take part in the process, and there are also mixed 
with the ear wax, little hairs and dead scales of epidermis. 

The covering of the external auditory canal is a continua- 
.tion of the common covering of the body, which externally 
retains all its coarse and fine anatomical peculiarities, losing 
its glands and becoming thinner as it passes inward ; and thus 
it can be easily understood, that the secretions of the auditory 
canal are commonly to be regarded as identical with those of 
the integument. This connexion or identity of the skin of 
the auditory canal with that of the body has been but little 
regarded, scarcely even noticed ; consequently too great an im- 
portance has been attached to it, especially as to its quantity. 
We may also turn our attention to these views of the impor- 
tance of an increase or diminution of the secretions of the ear, 
seeing if indeed there be so much. 



SECRETIONS OF THE AUDITORY CANAL. 35 

We find the cerumen, or ear wax, generally very hard in 
persons whose skins are dry and bodies wanting in fat. Thomas 
Buchanan, a Scotch physician in the first part of this century, 
wrote several books, in which it was said that, absence of 
secretion in the auditory canal was the cause of a great number 
of cases of deafness, and he made the secretions of the ear to 
play a peculiar and important part. These observations, in 
their time, found scarcely any attention or acceptance, although 
the dryness of the auditory canal is considered as a very 
important circumstance, both with the laity and the profession, 
with reference to acute hearing; and as remedies, pencil- 
lings and droppings of oils and balsams are practised, 
among which applications glycerine has lately come into great 
repute. You will seldom see an ear patient, who either 
through his own or a physician's recommendation, has not tried 
some such remedy. We find also, in all the books on diseases 
of the ear up to the latest time, the absence of ceruminons 
secretion regarded as of itself a cause for hardness of hearing, 
and a symptom of a deeper affection of the auditory canal. 
The abnormal dryness of the auditory canal, by the latest 
aurists, is generally considered to have great importance in 
catarrh of the cavity of the tympanum, and nervous deafness. 

A priori, we cannot deny that there is such a sympathy 
of the external auditory canal, and its secretions, with the 
deeper-lying parts of the ear, or that there is a certain physio- 
logical unity of the various parts ; certainly they stand in 
dependence the one upon the other. We can trace such a 
sympathy back to an anatomical basis, since the otic ganglion 
sends branches to the mucous membrane of the cavity of the 
tympanum, as also to the covering of the auditory canal. But 
what does our experience, our cool unbiased observation teach 
us here ? You must remember that very many ear patients 
very willingly ascribe the origin of their trouble to the accumu- 
lation of ear wax, and introduce ear spoons and such instru- 
ments; and in accordance with their own or a physician's 
recommendation, syringe the ear regularly. In this way an 
artificial dryness, a temporary absence of ear wax is produced. 
You should always inform yourself by questioning the patient, 
of the possibility of such a cause underlying the case. The 
examination of cases of chronic catarrh of the middle ear 



36 SECRETIONS OF THE AUDITORY CANAL. 

shows us, that sometimes the cerumen is deficient, sometimes 
present in too great a quantity. In short, there is no absolute 
proportion. But we will see later on, on what a slender foot- 
ing this absence of ear wax stands, in nervous deafness. Many 
surgeons say that in acute diseases, e.g. in acute catarrh of 
the middle ear, there is also deficiency in secretion. We 
cannot easily come to such a conclusion, for if the secre- 
tion went on normally before the attack, it is hardly possible 
that it has all suddenly disappeared. I hold to the belief that 
the idea, that deeper affections of the ear (we are of course not 
speaking of purulent affection) are regularly and proportionately 
connected with the diminution of secretion of cerumen, is 
purely traditional, and not confirmed by impartial observation. 
I can only ascribe the absence, diminution, or increase, as 
dependent upon the secretory power of the integument of the 
body. People who have an oily skin, people in whom the 
sudoriferous or sweat glands, especially of the head, are easily 
excited to action, have, as a rule, more cerumen in the ear than 
those whose skins are dryer and harsher. An insignificant 
quantity of ear wax is generally furnished. The superficial 
portion gradually becomes dry, and is lost, through the motion 
communicated to the cartilage of the canal, by the articula- 
tion of the lower jaw, also during the night in lying on the ear. 
If one has a vigorous secretion in the canal, more than ordinary 
being furnished, or than can be removed with the occasional 
aid of an ear spoon, or if there are circumstances which prevent 
the removal of the normally secreted wax, as is sometimes the 
case, in many cases of abnormal structure of the auditory 
canal, the secretion will gradually collect, and in a year can 
fully stop up the ear. The increased secretion of cerumen is 
by many authors referred to an acute inflammation of the canal. 
Kramer speaks of an inflammation of the cutis, whereby the 
ceruminous glands, lying under, are made to sympathize by 
an increased secretion of ear wax. Kau declares the increased 
secretion to be the result of an erythematous inflammation of 
the auditory canal. That hyperemia of the canal, inflammation 
or congestive irritation of the integument, increases its secretion, 
is true, from the nature of things will not be denied, and later 
on we will see how often Eczema and Furuncle in the auditory 
canal is connected with an abnormally great secretion of 



SECRETIONS OF THE AUDITOEY CANAL. 37 

epidermis and cerumen. Such irritations, however, must not 
necessarily be ascribed to the collection of cerumen, and I am 
of the opinion that the greater number of cases of closure of 
the canal by inspissated cerumen, must not be regarded as 
consequences of any kinds of acute and specific disturbance 
of the nutritive process; but only as a consequence of year 
long accumulation of increased secretion, which for some 
reason or other was not removed. All the symptoms which 
such patients commonly speak of — a great buzzing and itching 
in the ear, or the correctly given feeling, as if the ear were 
stopped up — are to be regarded as mechanical effects of the 
increased ear wax, and not as proofs of the described abnormal 
process, which the authors speak of. This conception is much 
simpler and more natural, and invites a careful and unpreju- 
diced observation. You have satisfied yourselves in our 
examinations which have lately begun, how different is the 
amount of cerumen secreted by different persons ; and I call your 
attention to the fact, that the auditory canal of many of our 
students had only a very little, while in others we found such 
a mass on the side of the canal, that it even prevented a full 
view of the membrana tympani. In these latter cases we can 
reckon on a gradual stopping up of the canal, if the collection 
of the secretion be not hindered. 

But the persons thus described were sure that they had good 
ears, heard perfectly well, and were not aware of any increase 
in the secretion. Interruption of the function of hearing will 
not show itself till the stoppage of the canal be complete. 
Such a deafness, arising from mechanical causes, excites a 
mass of other symptoms resulting from the pressure and irrita- 
tion, which is made by the dilatation of the foreign body upon 
the walls of the canal, and on the membrana tympani. In 
many cases the effects of the accumulation of cerumen take 
place so suddenly, that a person who a short time before believed 
that he had a perfectly healthy ear, at once finds himself hard 
of hearing. This can be explained in the following manner. 
Through some accidental reason, e.g. softening of the plug by 
the pouring in of water, changing its position after a concussion, 
or the like, the closure of the canal is suddenly rendered com- 
plete, and in this manner the abnormal condition is made 
known. 



38 SECRETIONS OF THE AUDITORY CANAL. 

An interesting case in which the relative worth of the history 
of the case, and the objective examination, are made known, is 
the following : An old man came out from a wine-house (bar- 
room), where he had taken an active part in the convivial 
proceedings, and on the way home struck against a wagon 
pole, awkwardly thrust out into the way, which knocked him 
down, striking his head upon the pavement. He thought that 
he lay there about fifteen minutes senseless. How far the fall 
or the several glasses of wine were to blame for this, he could 
not say ; he admitted, however,- to being a little intoxicated. 
However, he rose, and went home without difficulty. After a 
well passed night, he found in the morning that he was perfect- 
ly deaf. The physician who was called in, shook his head, 
and immediately ascribed the deafness to the fall, and striking 
the head on the pavement. He made a very serious matter of 
it to the family ; it was a concussion or perhaps apoplexy of 
the cerebrum. The patient, who in other respects was well, 
was placed on light diet, cupped, and purged, and after a few 
days a seton was added to the remedies. The deafness re- 
mained the same. A month elapsed, during which the patient 
sank bodily and mentally under the treatment. I was called 
in at about this time. After I had heard the history, I 
examined the ears, and found both canals fully stopped with 
cerumen. I caused this to be softened and removed by inject- 
ing warm water. In a few moments the patient heard perfectly 
well, and was cured, and not only from his deafness, but also 
from a " deep cloudiness of his intellect," which had occurred 
since the " concussion of the brain." Here the fall had displaced 
the already collected, but not yet observed mass of cerumen, so 
that the canal was immediately hermetically closed, hence the 
sudden deafness. Remember this case, gentlemen, when 
patients come to you, who present symptoms which can also 
possibly be referred to the ear, and think what an opinion this 
intellect-clouded, medicine-tormented, seton-bothered, and 
easily healed patient, must have had of his otherwise skilful 
physician, when the nature of the cerebral disease was made 
clear to both. Let us suppose that a few days after the applica- 
tion of the seton, the mass of wax, through any accident, had 
removed its position, or the physician had thought of apply- 
ing electricity, and accordingly had placed warm water 



SECRETIONS OF THE AUDITORY CANAL. 39 

in the ear, or if olive oil had been dropped in, and some of the 
cerumen removed, what a new proof would have been furnished 
of the effect of the remedies in cerebral deafness. 

Many patients affected with impaction of cerumen, tell 
us, that their condition varies in accordance with certain influ- 
ences. Many say that they become deaf, as quickly as they lie 
on the ear, and thereby press on it, and the deafness disappears 
as quickly as they rise and shake the head, or pull the ear. 
Others become deaf each morning as soon as they wash the 
ear, or clean it with a handkerchief. These are all circum- 
stances which go to prove to us, how masses of cerumen are 
affected by change of position ; and that the hearing power is 
first markedly disturbed, when it completely closes the auditory 
canal. Exceptionally, small quantities of cerumen can cause 
troublesome symptoms if it makes in the course of the auditory 
canal a thin but nevertheless complete partition wall ; or still 
more, when through any accident a thin flake lies en the 
membrana tympani, and therewith causes pressure and irrita- 
tion. 

I was once consulted by a patient, who, in consequence of 
deafness, had been treated for some time by injections of the 
ear. He had thus removed a considerable quantity of cerumen ; 
but in spite of it the deafness returned, and the buzzing sound 
greatly increased, and there was added to it severe pain 
and dizziness. The physician, who was little practised in 
diseases of the ear, could not clear up these symptoms, and 
sent the patient to me. I found the auditory canal free ; only 
a very small flake of dark-looking cerumen, disk-shaped, lay 
on the membrana tympani, by which it was entirely covered. 
I filled the ear with warm water, caused the patient to lie for 
some moments on the other side, and was able to remove the 
softened ear wax with a camel's hair brush. It caused for a 
moment a very severe buzzing in the ear, on account of the 
touching the drum, but all the symptoms afterwards subsided. 

The dizziness that is sometimes occasioned by plugs of ceru- 
men in the ear is very peculiar. We will again meet with this 
symptom in other affections of the ear. It has not as yet been 
fully comprehended, that> dizziness or vertigo can result from 
affections of the ear. Many patients hard of hearing, and 
suffering from this symptom, having been called " nervous" 



40 



SECRETIONS OF THE AUDITORY CANAL. 



and cerebral patients, have been sent the rounds of constitu- 
tional treatment at the springs, drinking vegetable decoctions, 
and finally have suffered from setons and the moxa, while the 
symptom should have been traced to the ear, and then perhaps 
could have been treated with some success. 

Wads of cotton, etc., which are often introduced into the 
ear, form the nucleus of a formation with which the auditory 
canal is sometimes stopped. It is not seldom that we find in 
the midst of cerumen,, a mass of little hairs, such as grow in 
the anterior portion of the canal, and such a discovery speaks 
for a very long continuation of the accumulation, it may be for 
ten years. Cerumen filled with such masses of hair, is found 
most generally in elderly persons, and this occurs not only 
because more time is given for their growth, but also, because 
very often a collapse of the walls of the passage takes place, 
and a slit-shaped canal is thus made, and thus the removal of 
cerumen more or less hindered. 

Such masses, however, accumulate in every time of life, 
even in childhood. In the last-named case, there is always 
much epidermis mixed with it, and the mass has a light yellow 
color.. Persons who have a very open, that is with sides 
widely separated, auditory canal, who suffer from a kind of 
catarrh of the part, are especially liable to the formation of 
these masses. I know the case of a young laborer, from whose 
ears I have removed these obstructions several times in the 
course of a year. Sometimes they consist of disk-shaped 
lamellae of epidermis, which are colored yellow or brown by 
a small quantity of cerumen mingled with it. Such cases 
cause us to ask, if in connexion with these there be not also a 
congestive irritation of the epidermis. You are generally able, 
in these cases, to distinguish old from new formations. The 
latter are peripheral in situation, are of a light color, are 
richly mingled with epidermis, and often show on the shining sur- 
face, resembling mother of pearl, a mixture of cholesterin crys- 
tals, while the older appear more amorphous and darker in color. 

Stopping of the ears with cerumen often takes place in both 
ears, in different grades of the formation, so that, for instance, 
in one ear, when complete stoppage has occurred, the patient 
is entirely deaf, while he thinks he hears normally well in the 
other, where only a crevice remains unfilled. 



SECRETIONS OF THE AUDITORY CANAL. 41 

These plugs of cerumen are by no means always of a harm- 
less nature, but through their great extent and consequent 
mischievous pressure, may work great damage upon the neigh- 
boring parts. Thus I made a post-mortem examination in a 
case,* when such a mass filled the whole auditory passage, 
certainly a very old mass, and had caused a dilation of all sides 
of the canal, and a perforation of the membrana tympani, so 
that a part reached into the cavity of the tympanum. 

Toynbee has had several opportunities to learn the evil 
effects which such masses cause to the neighboring parts. 

More than once, after the removal of such masses, I have seen 
the membrana tympani lying inwards, as if it had been pressed 
in this direction for some time. 

We should certainly be guarded in our prognosis, not 
immediately giving a favorable one, when we meet with such 
a collection, since the complications may often be so various 
and many.f 

From the foregoing it is evident that the surgeon, in the 
removal of these masses, must act slowly and with care, for he 
cannot know in what condition the deeper parts may be. You 
will never then begin with the use of forceps, ear spoons, etc., 
by which the plug is easily pushed inwards, and great pain 
and other results caused to the patient. The only proper 
method to be adopted, is the use of warm water injected, with 
which, however, we must use no violence. If the mass proves 
to be very hard, or the patient troublesome, we can fill the ear 
with warm water, and allow it to remain some time upon the 
plug, thus softening it, repeating the operation as often as 
may be necessary, and thus it may be easily loosened and 
swept out by the subsequent injections. Do not neglect to say 
to your patient to whom you intrust such a course of treat- 
ment, that this leaving water in the ear may cause his deaf- 
ness to increase, lest on following your advice he becomes 
worse and fails to return. 

* Yide the Author's Beitrage zur Ohrenheilkunde, Contributions to Diseases of 
the Ear, Yirchow's Archives, vol. xvi.; Sec. II. p. 10. 

f Toynbee, Diseases of the Ear, London, 1860, p. 48, of 160 ears where 
he had removed such masses, gives only sixty, where the hearing power was 
completely restored, in forty-three considerably improved, in the remaining sixty- 
two none or a very little improvement. The result of my observations has been 
similar. 



42 SECRETIONS OF THE AUDITORY CANAL. 

Oil and glycerine do not appear to loosen the masses so well 
as simple warm water. As the result of the syringing the 
mass is removed, very often in a large lump entire, and we are 
able to take it out, as it nears the meatus, with a forceps ; some- 
times thus we obtain a correct cast of the canal, on which we 
can see the figure of the outer surface of the membrana tympani. 

For a day after the mass is removed it is w r ell to guard the 
ear from cold and wind, by the introduction of a small piece of 
cotton. Those who are restored to hearing, after having been 
for a long time robbed of that sense, cannot bear great sounds, 
a loud voice being often very unpleasant to them. There is a 
slight congestion of the membrana tympani, and of the walls 
of the canal, immediately after the syringing, but this dis- 
appears in a few hours. 



LECTURE IV. 

STRINGING TIIE EAR. FOREIGN BODIES LN THE EAR. 

The Ear Syringe and Method of Use. — Some Methods of Removal 
of Foreign Podies,more dangerous than the Substances themselves. 
— Methods of Procedure in Doubtful Cases. — Foreign Bodies in 
the Far, often the cause of Peculiar Peflex Symptoms. — Cases. 

Gentlemen — A professor in an eminent medical faculty, to 
whom I announced my purpose to busy myself with the 
investigation and treatment of " Diseases of the Ear," answered 
me at once (of course, this was years ago) with a smile : 
" There is nothing more to do with ear cases than to syringe the 
ears, and put on a blister." Many intelligent and learned 
practitioners ascribe a similar high and universal value to 
syringing the ear. Perhaps then I may be excused, if I devote 
a few words to this simple procedure. 

Simple as it is, we will be able to satisfy ourselves, that very 
often physicians themselves cannot properly syringe the ear, 
and that there are medical schools where you may listen in 
vain for a passing word of instruction on the subject. But the 
thing is by no means an immaterial one. It is not only true 
that many patients by this simple process are immediately 
cured, but it is also true that there is a large number of 
patients, for instance those suffering from Otorrhcea, which 
before all things requires a regular removal of the secretion, if 
we would keep the process at a stand-still or improve it. We 
will later on inquire into all the circumstances which require a 
systematic and constant syringing of the ear, and we will learn 
that they are often cases which are accompanied by pain, and 
which often lead to Death. You see then, gentlemen, that 
much may depend on the knowledge of the proper time for 
syringing, and its proper manner. The subject is indeed very 
important in another sense than the one noticed above. 



u 



SYRINGING THE EAE. 

I show you here the instrument which I 
use, and which I also recommend to patients 
for their own use. It is of pewter or tin, has 
on its end a ring for withdrawing the piston, 
and has a blunt coniform extremity of bone. 
The portion lying next to the ring, and which 
unscrews, is somewhat broader and more pro- 
jecting, so as to afford a place for the two 
fingers to hold the syringe. The two rings at 
,the side which many aurists have seem to me 
superfluous. As we seldom need a long con- 
tinued stream of water, or great power of the 
stream, smaller syringes are greatly to be pre- 
ferred to larger. (Dr. Holcomb of this city has 
suggested the placing a tube of gutta-percha 
over the end of the syringe, and I find it use- 
ful and safe.) As I have already said, I re- 
commend this instrument to patients for their 
own use. I think horn and glass syringes the 
least practical. All the long tapering pointed 
instruments should be avoided, for the patient 
can easily do injury to the auditory canal with 
them, while the blunt point can be introduced 
without danger as far as it will go. 

In using the syringe, we remember the 
curvature of the canal, and that when we do 
not draw the cartilage upwards and back- 
wards, only the upper wall will be washed, 
while the deeper part and drum of the ear 
will be scarcely touched by the water. We 
take hold, then, of the cartilage of the ear with 
the left hand, as we have seen in the introduc- 
tion of the speculum. 

If you would be sure that the patient at 
home uses the syringe properly, you must 
give the necessary instructions. Many cases 
of otorrhcea are not cured, simply because the 
syringing is not done properly, that is, the 
secretion removed. The syringing must be 
done slowly, and without force, which we 



STRINGING THE EAR. 45 

must especially avoid in inflammations of the deeper parts, for 
these having become relaxed by the inflammatory process, 
may easily suffer injury. It is not to be doubted that a 
softened membrana tympani can be broken through by too 
strong a stream of water, and the ossicula auditus loosened 
from their connexion with a carious cavity of the tympanum, 
and that corroded walls can meet with further damage. 

Even when the membrana tympani is not relaxed, the 
syringing, be it ever so carefully performed, may excite a 
feeling of faintness, of dizziness, quickly passing away, which 
faintness, according to the invariable statement of patients, is 
not preceded by pain. 

Syringing the ear can only have one end in view, and that 
end is the removal of something from the ear, be it pus, 
inspissated cerumen, or any kind of a foreign body. When 
the examination has not shown us something to be removed, 
we should not attempt syringing. You may wonder that I say 
this to you, when it seems an axiom. You will wonder the 
more when, in your practice, you find that almost every ear 
patient, for whom you have not first prescribed, has been ordered 
to syringe the ear. The patients will often earnestly and truly 
inform you that nothing had been removed. 

You will see, then, that many physicians employ syringing 
as a diagnostic resource, in order to learn if the deafness do 
not depend on a collection of cerumen ; many also if the 
membrana tympani had not a hole in it. The patient has 
often a not inconsiderable evil added to his original trouble 
by such careless injections, especially if it be done too briskly, 
or, as is sometimes practised, very strong tea used. I have seen 
inflammations of the auditory canal, and of the membrana 
tympani, arising in such a way. 

We should never use cold water, only lukewarm, in the 
injection of the ear, the part being intolerant of anything cold. 
Anything more than water is not necessary. 

We turn now to the consideration of Foreign Bodies in the 
Ear. This chapter will lead us to speak less of the real 
importance of the subject, than of assumed and accredited. 
Children occasionally stick in the ear glass beads, fruit 
stones, and the like; moreover sometimes insects creep 
into the ear of older persons, and disquiet them through 



46 SYRINGING THE EAR. 

their presence. Generally the presence of these bodies in the 
ear is less injurious than the attempts to remove them. We 
may take for a motto the old proverb. " Blind zeal only does 
harm" (Blinder Eifer schadet nur). Really, we can but 
wonder how commonly the energetic methods of examination 
are undertaken by physicians as well as laymen, to see if the 
patient be really in the right, and a foreign body is in the 
auditory canal. There are some severe incidents of these 
circumstances, and the consequence of such unnecessary 
attempts, in Wilde's Aural Surgery, and such cases often lead 
to a tragic ending. In my own practice I remember two cases 
in point. 

I was once called out of bed by a servant girl, who with a 
woful countenance, and tears in her eyes, told me that an 
" Ohrenhollerer," the popular name in Franconia for earwig 
(Forficula auricularis), had crept into the ear, and that some 
persons had introduced a blade of straw in order to remove it. 
Luckily there lived a young surgeon in the house, who was 
also called, and by means of a pair of forceps took part in the 
search. He assured her that the animal was removed, but as 
she in the night had been attacked with severe pain in the ear, 
she thought the insect must be there. I illuminated the ear 
by means of a concave mirror and study lamp, and found 
certainly no insect, but a very much reddened auditory canal, 
and intensely injected membrana tympani, naturally the 
consequence of the search. 

A more serious case was the following : A young girl in 
the country, in sport one evening, had placed in her ear by her 
lover, a small piece of bread, which could not be removed. A 
surgeon, who was called in the night, looked for the foreign 
body by means of a probe, forceps, and scissors, and injected 
the ear with cold water. These attempts to get possession of 
the piece of bread, renewed several times, were at last obliged 
to be stopped, because a considerable bleeding from the ear 
resulted, and the patient, who had borne up well till then, 
declared that she could endure the pain no longer. To remove 
the inflammation cold water was applied to the ear for several 
hours. Some days after, I first saw the patient, and found a 
very severe and extensive inflammation of the auditory canal, 
it being very much swollen. In spite of energetic antiphlo- 



SYRINGING THE EAR. 47 

gistic treatment, the inflammation did not subside, several sub- 
cutaneous abscesses appeared in the depth of the auditory canal, 
and the local and general symptoms became so threatening, 
that I was for some days very anxious for the life of the patient. 
The inflammation gradually, however, abated, and in about 
four weeks she was able to leave her room. I confess this was 
a little too much for a piece of bread. I would leave such a 
foreign body to itself, for I cannot see how its presence would 
do harm, and it would probably during the night or following 
day go out of itself. If an insect or other animal creeps into 
the ear, then the simplest and best thing to do, would be tc 
fill the ear with water. The animal being thus inconvenienced, 
would creep out of itself (or be drowned and fall out). A 
great surgeon of our day, Malgaigne, recommends catching an 
animal which has crept into the ear, with a camel's hair pencil 
dipped in glue, and Verduc, to bait it with a piece of golden 
apple. Hyrtl well remarks that such remedies are too great 
burlesques for the serious mechanism of the surgeon. We can 
scarcely believe what ridiculous and laughable expedients 
have been suggested for the removal of foreign bodies from 
the ear. Thus the well known Itard recommends leaving seeds 
in the ear till they have sprouted, and then removing them by 
the sprouts. Bermond (1S34) reported that he had removed 
a bean by placing a leech upon it. Rau* from whom I take 
the last example, considers it as calling to mind the experi- 
ence of Arculanus (1493), who recommended to put the 
head of a freshly killed lizard in the ear. Three hours 
after the insect would be found in the mouth of the 
lizard. There is also a great number of forceps, nooses, 
perforators, etc., for the removal of foreign bodies from the ear. 
Some of them, of very complicated construction, and their 
number does not diminish even at this day. It is true that 
there is considerable room between the figure of a bead, and 
the oval or ellipsoidal contour of the auditory canal, so that a 
small lever can be introduced under the offending body. In 
such cases, however, injected water will also collect behind the 
body, and wash it out, or dislodge it so that the removal can 
be completed with my angled forceps, or with any thin and 

* Text Book for Diseases of the Ear. Berlin, 1856, p. 37G. "Lehr Buck der 
Ohrenheilkunde." 



43 SYRINGING THE EAR. 

broad body ; best, however, with a thin and broad lever, such 
as is found on the handle of Daviel's Spoon. If, however, there 
is no room between the walls of the auditory canal and the 
foreign body, we will only incur danger with any one of these 
instruments, i.e. danger of lacerating the wall of the passage, or 
of sinking the body still deeper, and of pressing it against the 
drum of the ear, whereby the condition of things will be made 
considerably worse. When there is no danger from delay, I 
would quiet the patient and those about him, set a leech or 
two on the meatus, if there be inflammatory symptoms, and 
afterwards cold applications. If, however, the swelling of the 
auditory canal does not disappear, and if after repeated 
syringing it is impossible to remove the foreign body, I would 
try if cataplasms developing suppuration would not bring it to 
the surface. If a case came under my observation where a 
wedged-in body produced such symptoms, that an energetic 
treatment for its removal was indicated, and delay as above 
recommended was not practicable, I would hasten to remove 
it by an operation, in which an opening should be made 
through the wall of the auditory canal, allowing us to fasten on 
the body from behind, and thus remove it. Paul von Aegina 
(1533), and the ancient surgeons recommended in such circum- 
stances, in cases of necessity, immediately to make a crescent- 
shaped incision behind the ear; and Hyrtl calls particular atten- 
tion to this method, which has been abandoned by Mai- 
gaigne, Rau, and others. I agree fully with the principle 
involved in this operation, although I would not enter from 
behind, but from above, thus choosing another position for the 
incision, and this for many reasons. 

The posterior auricular, artery runs immediately behind the 
pinna or cartilage of the ear, in the angle which it makes 
with the neck ; this is quite a large vessel, and this is the point 
indicated for an incision. In incising here, one could hardly 
avoid doing injury to the vessel. Furthermore, we will be 
prevented from separating the concha, and the cartilaginous por- 
tion of the auditory canal, on account of the prominence of the 
mastoid process, and are not able therefore with a bent instru- 
ment to go far enough. I have, however, satisfied myself on 
the dead body, that we can easily separate the auditory canal 
from the squamous portion of the temporal bone, and thus 



STRINGING THE EAR. 49 

with a bent aneurism needle, reach down to the membrana 
tjmpani. This operation is doubly easy in children, where 
there is scarcely any bony canal, and by the sinking in 
of the temporal bone, out of which the upper wall gradually 
forms itself, there is presented a very great inclined plane, so 
that it leads to the drum of the ear in a very obtuse open angle. 
In children, therefore, and here the cases occur most commonly, 
and sometimes the foreign bodies are pushed in further, by the 
efforts of a teacher or others to remove them, we can get at 
them from above, through the soft tender parts, reaching the 
membrana tympani, and the operation is less terrible and far 
safer than the commonly advised method. It is evident, gentle- 
men, that such a procedure must be reserved for cases of the 
most pressing necessity. Once more, never forget to assure 
yourselves that the story of the patient is true ; see if perhaps 
the auditory canal is not already free, and the symptoms are 
the result of attempts at extraction previously made. 

Furthermore, do not attach more importance to foreign 
bodies in the ear than really belongs to them, and try faithfully 
with syringing if you are not able to remove the body. 

Our aged fellow-countryman, the accomplished physician 
for the city in Nuremburg, says : "Chirurgus menti prius et 
oculo asfat, quam manu armata," in German, " Der Arzt 
muss zuerst iiberlegen und untersuchen, bcvor er operirt." 
The surgeon must look with eyes and mind before he operates. 
(I may here give the synopsis of a case belonging to this subject, 
which occurred while with my regiment in Pennsylvania in 
June of this year, and which appeared in the American Medi- 
cal Times. A sentry, while standing guard before the hospital 
tent, suddenly felt a bug creep into his ear. It occasioned 
vertigo, causing him to almost fall, and severe pain. I was 
not sent for, but attempts were made by non-medical men to 
remove it with forceps, etc., of course, with no knowledge of 
the situation of the bug. The attempt failed. The subsequent 
treatment when the case came to the assistant surgeon was anti- 
phlogistic, as considerable inflammatory symptoms had arisen, 
use of warm water. The subjective symptoms continued for 
ten days. I had no speculum in the army pannier, with which 
to make a sufficient examination, and on the tenth day the bug 
was removed by a long continued syringing.) 

4 



50 SYRINGING THE EAR. 

I would like now to call your attention to a class of cases 
which demand a careful regard. I would ask you to look for 
the explanation of many seemingly far removed cases of 
disturbances of the system in the ear, since the effects of irrita- 
tion of the auditory canal, especially those from the long 
continued presence of foreign bodies, often locate themselves 
in other nerve channels, and are capable of making a long 
continued source of trouble. You all very well know, that 
contact with the auditory canal often produces tickling in the 
throat, and that the introduction of an ear speculum causes 
many persons to cough. You know that these reflex nervous 
phenomena must depend on the supply of nerve material from 
the pneumo-gastric to the epidermis of the auditory canal. 
We have also seen that some persons experience sensations of 
dizziness in syringing the ear, and that masses of cerumen 
pressing on the ear can also excite such symptoms. Such 
patients are considered as suffering from cerebral disease. 
Pechlin has observed a case, in which touching the external 
auditory canal excited severe vomiting ; and Arnold tells of a 
girl who suffered from a severe cough and expectoration, often 
returning, and thereby visibly emaciating her. On closer 
examination she confessed that she placed a bean in each ear, 
as she had been advised to, on account of noises in the head. 
The removal of these beans was accompanied by severe 
coughing, vomiting, and sneezing. The symptoms then ceased, 
and the girl fully recovered.* 

In a case observed by Toynbee, the patient suffered from 
severe cough, which was not alleviated by treatment, but 
which ceased as soon as a piece of necrosed bone was removed 
from the auditory canal. Bayer relates a case from the 
practice of Fabrizius von Hilden, where a girl who suffered 
from epilepsy, atrophy of one arm, and anesthesia of an entire 
half of the body, was cured from all of these symptoms by the 
removal of a glass ball from the ear, which she had placed 
there eight years before.f . Wilde relates a case of epilepsy 
and deafness, which, according to the view of the observer, 
arose from the presence of a foreign body in the ear, and was 

* Romberg's Text Book of Nervous Diseases. Berlin, 1851, vol. ii., p. 130. 

\ Boyer, Surgical Diseases. Wurzburg, 1821, vol. vi., p. 10. , 



SYRINGING THE EAR. 51 

relieved by its removal. It is well known that epilepsy and 
other nervous diseases can occur as reflex symptoms, and from 
the pathological irritation of peripheral nerves, as well as from 
the irritation of the nerve centre itself. 

When we consider these facts, and the supply of the ear, in 
sensory branches from the trigeminus and pneumo-gastric, 
taken in connexion with the above experience, we will not 
too generally assign other causes for extraordinary symptoms, 
until we ascertain if there be not a possibility of their arising 
from the ear. 

Later on, in the course of our meeting together, we will 
speak more fully of the general symptoms, which are more or 
less connected with affections of the ear. 

From a consideration of all these facts, gentlemen, I do not 
believe myself presumptuous, when I hope there is a day 
coming, when, in a considerable number of diseases, intelligent 
surgeons will consider the ear as well as the pupil as a part to 
be always examined. 



LECTURE V. 

FURUNCLES IN THE AUDITORY CANAL. BLOOD-LETTING IN EAR 

DISEASES. 

Symptoms^ Course, and Treatment of Furuncle.— Place of Blood- 
Letting, in accordance with the Situation of the Affection. — Some 
Hides for the Use of Leeches. 

Gentlemen — In coming to-day to speak of the inflammation 
of the auditory canal, we must notice first, Follicular Abscesses 
or Furuncles. 

Furuncles of the auditory canal are exactly similar in their 
nature to the Furuncles which so commonly appear in other 
parts of the body. It is well known that this form of abscess 
distinguishes itself from other in that the Furuncle has in its 
centre a circumscribed " core," which is formed from dead 
connective tissue, and also from a diseased hair cyst. The 
inflammation generally begins in the hair cyst, and as a 
consequence of the profuse formation of pus, this cyst, as 
also the connective tissue about, is destroyed. 

A so called demarcated, or circumscribed inflammation 
develops itself about this " core," and thus furnishes still more 
purulent matter ; since, however, the central mass of connect- 
ive tissue becomes fully separated, the furuncle presents a 
great similarity to an abscess. 

These circumscribed abscesses may be described as swellings 
of varied size ; flat round in shape, of firm consistence, with 
broad bases, and without a well defined border, proceeding from 
the integument of the auditory canal. Their color often scarcely 
changed from that of the skin, seldom more than a pale red, 
always very tender to the touch ; the surrounding parts are 
more or less swollen, so that a complete closure of the auditory 
canal, and with it hardness of hearing or deafness, may occur. 
Sometimes the borders of the swelling are so little to be 



FURUNCLES IN THE AUDITORY CANAL. 53 

distinguished, or the meatus auditorius externus so extremely 
slit-formed, that we can with difficulty find and designate the 
exact position of the abscess. Several furuncles often appear 
near each other, whereby the symptoms are very naturally 
increased. The subjective symptoms from such follicular 
abscesses are as various as those occurring in other parts of 
the body, according to position and extent. In the beginning 
the patient experiences little more than a troublesome fulness 
in the ear, as if the ear were stopped up. Soon severe pain 
occurs, extending from the ear to all the surrounding parts, 
occurring in chewing, speaking, and in other movements of 
the under jaw, and this pain always increases at night. The 
patient complains of a feeling of extreme tension in the ear, of 
a continual noise of pounding and hammering in the head, 
and the patient cannot lie on the affected side ; because at each 
motion unbearable pain is occasioned. In such cases, the 
unrest and excitement easily change to a state of fever, and I 
have been before now called to patients, whose countenance 
and statement would have induced me to fear inflammation 
of the middle ear as the cause, instead of simple furuncle ot 
the auditory canal. The symptoms are uncommonly various, 
even when the inflammatory symptoms are equally extended 
over the auditory canal, owing to the peculiar formation of the 
cartilaginous portion, which, as you remember, is to a certain 
degree like that of the trachea, since it has a number of gaps, 
or fissures, filled only with fibrous tissue, "incisurse Santorini." 

Furthermore, on the upper wall a stocking-shaped piece of. 
integument reaches into the bony part of the canal, and this has 
just as dense connective tissue, glands and hair cysts as any 
other part. If now, furuncles should occur in such a position, 
when the inflamed, swollen, connective tissue cannot be ex- 
posed, and when it quickly reaches a firm unyielding basis, viz. 
the bone, the symptoms depending on tension of the connective 
tissue will be much severer, while if we reverse the case, 
such a follicular abscess will be little noticed, if it be situated 
at the entrance of the auditory canal or other similar favorable 
positions. 

Furuncle of the auditory canal appears in every age, and in 
the most different kinds of constitution. They often occur as 
complications of otorrhoea, when frequent syringing is made 



54 FURUNCLES IN THE AUDITORY CANAL. 

use of, and also when the affection is left entirely to itself. 
A lotion of alum appears to produce them. A young medical 
man whom I treated with an obstinate case of inflammation of 
the membrana tympani, with purulent discharge, and whom I 
advised the use of the above named astringent, and in order to 
produce a full effect to leave it in the ear during the whole 
night, closing the ear and sleeping on the other side, had 
regularly, as often as he tried this remedy, a small abscess in 
the auditory canal, while he could use the same astringent for 
months if he left it in but a short time. 

As to the course of this affection, resolution sometimes occurs 
without there being a discharge of pus ; generally, however, a 
thin yellow point forms, and an opening follows from three to six 
days from the beginning of the attack. Then the scene ends, and 
at one stroke all the disturbing symptoms disappear, if a new 
furuncle does not immediately set in. The contents are 
generally a few drops of thick pus, and a fatty or flocculent 
mass, which we can commonly obtain by pressure on the walls 
of the abscess. The discharge of pus soon ceases ; just before 
the opening we find the surface covered with a smeary 
moistness. 

The Prognosis should be stated as a thoroughly good one, if 
we except therefrom the fact, that often many such abscesses 
follow each other in a more or less rapid succession. It is well, 
then, to tell this to the patient if only one has occurred ; or 
this frequent return of such abscesses, continuing even through 
a long period of time, may become in the highest degree 
annoying, and a real source of trouble, although in themselves 
they are unimportant and without consequence. 

I once treated a man, who for twelve years long, with 
intervals of two weeks, and at the highest two months, suffered 
from such furuncles, now in one, now in the other ear ; and 
with which there was always general febrile disturbance, so 
that at each attack he was obliged to lie some days in bed, and 
thus on account of this affection hindered in his business, 
which was that of cattle-dealer. 

Almost all persons who complain of frequently recurring 
year-long-continuing furuncles in the auditory canal, are in 
other respects entirely well, some of them even of strong 
constitution, in the prime of life, more females than male. 



FURUNCLES IN THE AUDITORY CANAL. 55 

Treatment. — Wilde speaks highly of the use of nitrate of 
silver, as an abortive remedy. If the inflammation has jnst 
begun, he thinks by this means to have often cut 
short the process, and prevented the formation of pus. 
I have no experience in the remedy, yet I would 
think it worth the trial, in many cases. Warm, greasy 
applications are of service in these cases, because 
they decrease the tension, and hasten resolution. 

We may fill the ear with warm water when it is possi- 
ble to do so, more than is already done by the furuncle, 
place a small cataplasm upon the ear, or let the steam 
from a vessel of warm water stream against the affected 
part. (This last named will be found, I think, the most 
efficient and soothing remedy. Let some aromatic 
infusion be made, as ihr instance of catnip (cataria). 
The steam of this will be very grateful.) If any 
constitutional disturbance exist, give a saline cathartic, 
I have not generally found leeches necessary. If used, 
they should be applied near the meatus, just in front 
of the tragus. 

I incise the furuncle as quick as possible, not waiting 
by any means for the formation of pus ; the quicker we 
use the knife, the better. If a complete abscess has 
formed, the pus is discharged, and all the pain ceases 
therewith. If, however, it has not gone so far, generally 
the process is cut short, or at least the further severe 
pain is spared the patient. The incision should be 
deep and free. The skin of the cartilaginous part of 
the auditory canal is very dense and somewhat 
thick, therefore the knife must be used with some 
force. A slender, tapering pointed bistoury with a 
long handle, which has on the other extremity a 
Davielschen spoon, as used in extraction of cataract, 
with which to complete the emptying of the ab- 
scess, has proved very serviceable to me in this and 
fig. 4. similar incisions. 

This little spoon can be used instead of a probe in finding 
the situation of the abscess, which cannot always, as has been 
already shown, be discerned with the eye. If we have found 
the most painful spot, this is the one to be cut, and the instru- 



56 FURUNCLES IN THE AUDITORY CANAL. 

ment should be immediately reversed, and the incision made 
without giving the patient the pain of awaiting it. The cutting 
does not cause half so much pain as the knowledge that the 
next thing is the cutting, and with all over anxious knife-fearing 
patients, if you stop to parley you will end with the same. 
Immediately following a rightly located incision, a great relief is 
experienced, even when no pus is evacuated, through the 
relaxation of the parts, and also through the blood-letting, 
which is sometimes not inconsiderable. We inject immediately 
after opening the abscess warm water in the ear, in order to 
expedite the removal of blood and pus, and advise the patient 
to continue the warm vapor, in order that the swelling may 
quickly and entirely disappear. You will, of course, under- 
stand that you are not to make an incision, which is always a 
painful thing, if the patient is scarcely troubled on account of 
the furuncle, and if you see from its situation that it will cause 
little inconvenience. Always advise such patients to visit you 
a week later, or to once carefully syringe the ear, at about that 
lapse of time, because after a furuncle, still more so after a 
series of them, increased secretion of epidermis and cerumen 
occurs, whereby a closure of the auditory canal may occur. 
It is also well to remember that this discharge may be an 
inducement to the formation of subsequent abscesses, perhaps 
though irritation of the hair cyst, or stoppage of the exit of the 
ceruminous glands. It is entirely wrong, however, as many 
patients are advised, to syringe the ear without cause, after 
furuncles have been present. 

(When these pages were ready for the press, a case occurring 
in the practice of my friend Professor Post of this city, which 
seems of enough interest to be inserted here, came to my 
knowledge. The Doctor was sent for to see a lady suffering 
from swelling and pain in the ear. He found it to be a case 
of phlegmonous inflammation, situated in the meatus audito- 
rius externus, which had existed for some days with agonizing 
pain. Following his usual practice, he determined to make an 
incision, which was done, giving some relief, but not the usual 
amount of immediate freedom from pain. There happened to 
be a gentleman in the same house suffering from the same 
affection. The professor immediately opened this also, and 
immediately, or within a very few ruinntes, complete relief 



. FURUNCLES IN THE AUDITORY CANAL. 57 

was experienced. It was nearly dark, and from the haemorrhage 
occurring from the incision in the first case, an examination of 
the external canal was not practicable ; but Dr. Post expressed 
the opinion that there was another abscess in the meatus, and 
that this was the reason the pain was not so completely relieved 
in the case of the lady as in the gentleman. Subsequent 
examination proved this to be true, when an incision was 
made and full relief followed. Too much stress cannot be laid 
upon the necessity for early incisions in these cases. The 
patients will thank you for them, and condemn those who 
attempt to wait for a natural opening, as so many physicians 
are inclined to do). 

As to constitutional treatment, I have tried the mineral 
springs and other constitutional treatment to prevent their 
return, but as yet have found them of no effect. 

In the following lectures, we will speak of blood-letting, and 
of the use of leeches, in affections of the ear, and I will now 
speak more particularly concerning the method. Local blood- 
letting, in some inflammations of the ear, is a very powerful 
remedy, and I know of none, when you have such an immedi- 
ate effect; nevertheless it requires to be used rightly, with 
observance of certain rules, and careful observation, or it will 
do no good, on the contrary, harm. You will generally find 
the mastoid process chosen as the place at which to apply a 
leech. Wilde first called attention to the fact, that in the 
most painful of ear affections, and these are inflammations of 
the external auditory canal, and of the membrana tympani, 
a small number of leeches applied on the meatus do 
much more good than a greater number applied behind the 
ear. The recent observations which I have made on the course 
and origin of the vessels of the external surface of the drum of 
the ear, furnish us with the anatomical reason for this fact. 

For we know, that the external auditory canal and membrana 
tympani derive the greater portion of their common blood 
supply from the branches of the art. auricularis profunda, 
which runs behind the condyloid process of the under jaw, i.e. 
in front of the meatus auditorius externus, and supplies first 
the tragus, and anterior part of the auditory canal. In front 
of the meatus also lies the vena auricularis profunda, the 
chief vein of the outer ear. If we will then in any affection 



58 FURUNCLES IN THE AUDITORY CANAL. 

draw blood from the part nourishing the external ear, we 
will select, not the mastoid process, but the meatus, especially 
the tragus, and the vicinity immediately about it. It is, how- 
ever, difficult to accomplish this in deeper affections, e.g. 
of the cavity of the tympanum. In such cases, where, 
however, we have not much to hope for from blood-letting, 
we can make the application on the mastoid process, and in 
front of the ear, since we learn from anatomy the cavity of the 
tympanum and the neighboring bones draw their blood supply 
from various sides, partly from the tympanic artery, which 
passes through the glaserian fissure, i.e. at the articulation of 
the jaw, and from the stylo-mastoid, which enters under the 
meatus into the fallopian canaL 

The mastoid process and the bordering bones receive their 
supply from the arteries of the dura mater and pericranium, 
internal and external. This process is penetrated by a number 
of vessels, which furnish the connexions between the veins of 
the soft covering of the skull, and the sinuses and veins internal 
to the calvarium. (Yen^e diploicse temporales posteriores, 
venss emissariae mastoidal.) 

In drawing blood from the mastoid process, we are 
able to cause a quick and full stream to flow, especially by 
means of Hourteloup's artificial leech, and to take blood not 
only from the periosteum, but also from the veins and sinuses 
on the interior of the skull. (The artificial leech is used a 
great deal in Germany, especially in Professor Graefe's Ophthal- 
mic Hospital in Berlin, and with seeming excellent results. 
It may be obtained in ~New York.) This much then as to the 
position for local blood-letting according to the cases. 

I have still to add a few rules for the application of leeches 
near the meatus. You should indicate the place of applica- 
tion with ink. If you do not close the auditory passage 
with cotton, blood will run in, which may coagulate there, 
and increase the malady of the patient ; the leech itself may 
also get in. A colleague told me, that he once applied a leech 
to the ear, it crept in, and caused such excessive pain, that he 
thought it must have bitten the membrana tympani, and so it 
remained during an exceedingly troublesome hour. I think 
in such cases we could help the matter by dropping in a solu- 
tion of salt. It is best, however, to prevent such an accident 



FURUNCLES IN THE AUDITORY CANAL. 59 

by stopping up the auditory canal. Further, it is well to tell 
the patient the means of arresting the bleeding, for occasionally 
the haemorrhage proceeds further than is wished, especially in 
the temporal and aural region. I know a case, in which a 
leech placed upon the temple, was the immediate cause of 
death in a child of two years of age, because those about were 
not able to check the haemorrhage. After the bleeding has 
ceased, cover the bite with a piece of court plaster, or similar 
material. There are cases which react after every leech bite 
with erysipelatous swelling of the face and head. Whenever 
the wound easily becomes unclean, as for instance in otorrhoea, 
this is very apt to be the case. It is not long since that I 
saw, it on a patient for whom I had ordered a leech applied, 
extending from the place of application, over the whole face, 
and which assumed such proportions, that it was only by the 
most energetic means that I could restrain its progress. In 
this case I had every reason to suppose that the erysipelas 
arose from contact of an otorrhceal discharge with the wounds 
of the leech. "Little causes, great effects," is a sentence whose 
full import is yet to be comprehended in the practice of 
surgery. Do not consider little things too lightly, and you 
will very often guard against great injury, 



LECTURE VI. 

DIFFUSE INFLAMMATION OF THE AUDITORY CANAL, OH OTITIS 

EXTERNA. 

Periostitis of the Auditory Canal, no Independent Process. — Dif- 
ferent Causes for Otitis Externa. — Acute Form, with its Subjec- 
tive and Objective Symptoms. — The Chronic Form. 

Gentlemen — As we in our last lecture considered the circum- 
scribed inflammation of the auditory canal, the follicular 
abscesses, or furuncle, we come naturally to-day to speak of 
the diffuse inflammation of the same part, or of Otitis externa. 
I think I am sustained by clinical facts, in classing together 
the various forms of diffuse inflammation of the auditory canal, 
under the common name of otitis externa. In order to a better 
understanding of the nomenclature here adopted, allow me to 
say, that by Otitis interna I understand the purulent catarrh 
of the middle ear, or cavity of the tympanum. The simple 
mucous catarrh, I call simply aural catarrh. By otitis I under- 
stand all forms of inflammation, which cannot be confined in 
description to one particular part of the ear. (The author's 
nomenclature as here given, and as will be subsequently deve- 
loped, is as follows in the order met with in his book : 

1. Furuncles in the auditory canal, or circumscribed inflam- 
mation. 

2. Otitis externa, or diffuse inflammation. 

3. Myringitis, or inflammation of membrana tympani. 

4. Aural catarrh, or mucous catarrh of the middle ear. 

5. Otitis interna, or purulent catarrh of the middle ear. 

6. Aural polypi. 

7. Otitis, or general inflammation of the various parts of 
the ear. 

8. Nervous Deafness). 



INFLAMMATION OF THE AUDITORY CANAL,. 61 

Some authors, among whom are Kramer and Rau, distinguish 
between an inflammation of the cutis and periosteum. Defi- 
nite observations, on a primary, isolated inflammation of the 
periosteum of the auditory canal, are not presented. The cases 
which are reported under this name, are long standing affec- 
tions, in which nothing at all can be shown to indicate that the 
bone was the part first affected. On the contrary, we are often 
able to observe inflammations of the integument of the auditory 
canal, which afterwards produce affections of the bone lying 
under, and it seems to me much more probable that the perios- 
tisis is always a consequence, a follower of a severe and neg- 
lected inflammation of the cutis. 

Not only do clinical observations lead to such a view, but 
the anatomical facts speak further on the subject. Cutis and 
periosteum are generally so intimately connected with each 
other in the bony portion of the canal, that the latter can 
scarcely be isolated, and is more easily separated from the cutis 
than the bone. In consequence of the close connexion of 
these two parts, every intense inflammation of the cutis also 
has its effect upon the periosteum, and may even produce 
inflammation, and subsequent caries. Many writers, among 
whom is Toynbee, speak of a catarrhal inflammation of the 
auditory canal. The integument is certainly always thinner 
and softer, the more it nears the membrana tympani, but this 
does not make it a mucous membrane, but a kind of middle 
material between mucous membrane and common integument, 
such as we everywhere see where these two tissues join each 
other. The name catarrh, according to common modes of speech, 
only pertains to affections of the mucous membrane, its use for 
inflammations of the external auditory canal is not proper, and 
the name Aural Catarrh should only be used for the middle ear, 
which is really covered with a mucous membrane. Itard speaks 
of a " Catarrhal otitis externa," and of a " Purulent otitis 
externa," both of which names are equally incorrect. The 
only distinctions we are able to make in the external auditory 
canal, are between an acute and chronic diffuse inflammation, 
or otitis externa. 

Otitis externa is an uncommonly varied appearing, polymor- 
phous affection. Sometimes occurring entirely unmasked, 
runs its course without any marked effect, either locally or 



62 INFLAMMATION OF THE AUDITORY CANAL. 

constitutionally, and disappears without treatment. Even so- 
often it appears suddenly, and with very disturbing and annoy- 
ing symptoms, which are not only felt in the ear, but place the 
whole organism in a febrile condition, often continuing a long 
time, then disappearing and returning, each time bringing 
with it a deeper affection, and making life a burden on account 
of the severe pain accompanying it, and often making the 
patient's existence doubtful. Each inflammation of the ear 
can reach such a point of danger, and it is certainly wrong 
that their presumptive unimportance should lead us to regard 
them lightly in the outset. We should never neglect the treat- 
ment of otitis externa, because after it a certain degree of deaf- 
ness and purulent discharge almost always remains. 

It is an affection which may appear in every time of life, by 
far more commonly, however, occurring in childhood and 
infancy. 

JRau calls attention to the fact, that each new cutting of the 
teeth in some children is accompanied by irritation of the cutis. 
The Causes are in the highest degree various. It may occur 
from acute and chronie exanthemata, which extend from the 
integument of the face to that of the ear. Thus measles, scarlet 
fever, and small-pox, not only attack the mucous membrane of 
the ear, first, but also the integument. The eczematous erup- 
tions of the face which are so common, may extend themselves 
to the ear, or exist there independently and primarily. I have 
more than once observed in patients with constitutional syphi- 
lis a moist, variety of condylomata appearing on the meatus 
auditorius, &c, and after this had occurred gradually a mild 
form of inflammation and purulent discharge from the auditory 
canal appeared. On the post-mortem of one patient suffering 
from pemphigus, I found that the skin disease had extended 
to the auditory canal, and to the membrana tympani. Otitis 
externa occurs quite as often from irritations, and injuries of 
various kinds working from without. Some ladies are in the 
habit of dropping Eau de Cologne in the ear for the relief of 
toothache, as recommended by Malgaigne, and by this means 
diffuse inflammation may be excited. I saw a case of inflam- 
mation arising from frequent and long continued injections of 
the ear. 
Such an affection is very apt to arise, and that of the severest 



INFLAMMATION OF THE AUDITORY CANAL. 63 

form, after foreign bodies have been removed with an unneces- 
sarily great degree of energy. 

Cold upon the ear, as for instance a draught of air blowing 
upon the head, in the case of working near a broken window, 
or cold water being introduced, are frequent causes of otitis. 
Cold is not generally well borne by the ear, and we should pro- 
tect it more than is generally done. (The traveller in Germany 
cannot fail to observe the great prevalence of the habit among 
the people of all classes of stuffing the ear with cotton, even in 
the mildest weather. I believe this is about as sensible a prac- 
tice as stuffing the nostrils would be, the natural curvature of 
the auditory canal being protection enough from the open air. 
The cartilage of the ear will be frozen before the membrana 
tympani or canal will be inflamed by the contact of cold air, 
provided it does not reach it through a narrow aperture, as in the 
case of a broken window. Ladies generally cover their ears 
with their hair or bonnet, and the amount of deafness is j ust as 
great among them as with the other sex. I cannot but enter my 
protest against this practice of indiscriminately filling the audi- 
tory canal, which Dr. Troltsch barely suggests, but which Kra- 
mer and others advise. I do not believe there is a case on 
record, where inflammation of the ear has resulted from leav- 
ing the meatus uncovered in an open cold air. If the body 
becomes chilled, or the feet wet, or a narrow draught of air 
blow directly upon the head, this inflammatory action may 
result, and thus cold becomes one of the causes of deafness.) 
All fluids to be placed in the ear should be previously warmed, 
lest they excite unpleasant, if not positively injurious effects. 

So insidious is the affection sometimes that we cannot find 
any visible appearance of it. Such cases occur very often in 
children, as well in those who are healthy, and those who are 
inclined to glandular affections, eruptions on the skin, and are 
denominated scrofulous. I cannot warn you enough, gentle- 
men, from the too frequent use of the diagnosis " scrofulous." 
It is among too many, a convenient expedient to get rid of 
aural examination of the affected portion, and of a tedious and 
wearisome local treatment. The diagnosis scrofulous plays a 
great part in diseases of the ear, and a fatal one, and yet the 
chief foundation for this opinion, enlarged cervical glands 
are often only consequences of neglected discharges from the 



6-i INFLAMMATION OF THE AUDITORY CANAL. 

ear. If this be treated, the enlarged glands disappear. We 
find catarrh of the cavity of the tympanum as a complication of 
otitis externa very often in children, just as very often in chil- 
dren affections of the skin and mucous membrane often occur 
together. The causes which produce this disease are very 
many, so that the friends of classification and sub- classification 
may have there a great list of them. Thus they may classify 
them according to the degree of the affection, and the severeness 
of them, as erythematous, erysipelatous, and phlegmonous ; 
according to the ascertained constitutional affection, morbil- 
lous, scarlatinous, or variolous, as scrofulous or syphilitic, as 
rheumatic or traumatic, etc., etc. 

All these various forms do occur, and it cannot be denied that 
the course of it may be very much modified by the cause. 
For practical purposes, however,' such qualifications are of no 
use to us, and you should not plague yourselves with their 
memory. 

The symptoms and course of otitis externa, as we see from 
the foregoing, are various, according to the producing causes, 
their variety and intensity. 

In the acute form of otitis externa, the patients generally 
complain of an itching, with a feeling of heat and dryness in 
the ear, and the itching or tickling sensation is so great in 
some, that they are scarcely able to refrain from placing some 
kind of instrument, as an earspoon, or the like, into the ear. 
The cessation of this symptom is followed by pain; a dull 
heavy pain, rising to a severe beating, which is felt deep 
in the ear, almost always occurring in the night, and with loss 
of sleep, feverishness, it goes on easily to delirium. Pains 
declaring themselves in the deeper parts of the ear, extend 
themselves in severe cases to the whole side of the head. They 
are increased by every motion of the body, still more of the 
head, as in sneezing or coughing ; by any motion of the jaw, 
as in chewing and yawning. The latter named symptoms 
occur more particularly when the anterior portion of the ear 
is affected, and the cartilaginous portion takes part in the 
swelling. In trivial cases, the anterior region is not much 
swollen, but very tender on pressure. The vigorous moving 
of the canal, as for instance in straightening it for examina- 
tion, causes pain, and the ear speculum should be introduced 



INFLAMMATION OF THE AUDITORY CANAL. 65 

very carefully and slowly. The hearing power is affected 
according as the membrana tympani takes part in the inflamma- 
tion, and this is always more or less involved. If we examine 
the ear in the beginning of the attack, we find the epidermis 
with the surface of the drum greatly injected, and swollen. 
The injection and hyperemia show themselves more clearly 
on the membrana tympani, and the adjoining parts, because, in 
the outer portion of the canal, the congestion is concealed by 
the thicker surface of epidermis. 

After the congestive stage has lasted seldom longer 
than two or three days, an exudation appears. In the 
beginning this is of a white color, watery in consistence ; a 
little later on it becomes a kind of mucous secretion, and at 
last yellow pus. Coincident with the appearance of this 
otorrhoea, which in the beginning is slight, but which is 
always increasing, the patient feels a great improvement and 
the pain suddenly disappears. In some cases this otorrhoea is 
not so much a formation of cells, as a very rich desquamation, 
so that in a ^short time the whole auditory canal is filled 
with a white, moist, as it were, macerated lamella, which 
I have seen more often on the drum itself, than other parts. 
"We can, by injections or by means of delicate forceps, remove 
a number of white flakes of the size and form of the membra- 
na tympani, which are certainly furnished by its outer surface ;. 
some are also the shape of the walls of the canal. I have 
mostly observed such desquamations in cases where the pain 
was very severe and extended, for the reason that the pain 
and importance of the affection is the greater, the more the 
membrana tympani and deeper parts are involved. If we make 
an examination later, or during the exudative stage, the canal 
must be previously cleared by injections or pencillings. If 
the injection tube be very large, and the stream very strong,, 
it is easy to perforate the membrana tympani. On account of 
the great amount of swelling and infiltration, it is difficult to 
appreciate the condition of the different parts of the canal r 
especially the deeper ones, their appearance and relative posi- 
tion being greatly changed. The examination is also often 
made more difficult, on account of the amount of the secretion 
adhering to the wall, and on account of the saturated scales of 
epidermis, which are in the light, and which can only be slowly 

5 



66 INFLAMMATION OF THE AUDITORY CANAL. 

removed. If, however, in spite of the hindrances, we succeed 
in getting a good view, we see the walls of the canal appear 
saturated and swollen, more or less denuded ; and when the 
latter is the case, the membrana tympani presents an equally 
red surface, in which no single vessels can be distinguished 
resembling a granulating wound, or a blennorrhagic conj nnctiva. 

Often in these cases, where the desquamating process has 
taken place, there are small spots covered with isolated bits 
of epidermis, or with a thin layer of pus, which if removed 
appears again, almost before our very eyes. Afterwards, the 
otorrhcea appears, which stage is generally blessed by both 
physician and patient, because the pain generally ceases. 
This otorrhoea may continue a long time, or it may, under very 
favorable circumstances, and without treatment, gradually and 
entirely disappear. 

Much more often, however, it becomes chronic, and when 
nothing is done for it, lasts for years, in various and variable 
degrees of intensity, and may continue with some 'insignifi- 
cant interruptions throughout the entire life. A great number 
of otorrhcea cases coming under treatment, may be referred 
back to such a starting point. Yery often, however, patients 
presenting themselves with otitis externa, do not speak of such 
a painful origin ; it has had a much more insidious character. 
Such a chronic form of disease is quite as common as the acute 
form, and arises without marked symptoms, occurring as often 
as that springing from neglect of the acute. 

The subjective symptoms are very evident. The nose will 
call attention to the affection. 

The painful symptoms sometimes recur, even when the 
trouble has existed for a long time, with no more disturbance 
than a discharge from the ear, and some hardness of hearing. 
Sometimes the otorrhcea only appears periodically in moist 
summer weather. In this form we find the canal only a little 
swollen, its covering softened, as if macerated, injected, and 
covered with a secretion — brown, offensive smelling crusts. 
The general redness is only to be observed in the deeper 
parts, and on the membrana tympani. This seems flattened, 
its cutis thickened, and it is richest in this over the malleus, 
which is scarcely to be seen. The amount of the secretion is 
very various, changing according to the time of year, and the 



INFLAMMATION OF THE AUDITORY CANAL. 67 

other influences ; at one time the meatus is almost dry ; again, 
there is a profuse discharge, which excoriates the skin of the 
ear and neighboring parts, and soils the clothes of the patient. 
I have never been able to measure the exact amount of the 
discharge, but I have seen cases where it was at least from 
three to four ounces daily. Such cases of profuse secretion, 
we find generally in the case of children of the peasantry, who 
are not always kept clean, .who even advocate the continuance 
of the filthiness, by saying that the disease must be cured by 
constitutional remedies (von innen heraus), and not by " driving 
it in," which causes dangerous internal diseases to arise. These 
children, who, except as to the ear, are specimens of freshness 
and health, are treated for months and years with iodide of mer- 
cury, Plummer's pill, laxatives, etc., all sour and fat food, even 
fruit, forbidden them ; and as if the region of the ear were not 
irritated enough, it is made so by means of tartar emetic oint- 
ment, and other vesicants. In short, all the remedies on earth 
will be brought to cure the discharge of the ear, without 
thinking of the first surgical as well as domestic law, clean- 
liness. 



LECTURE VII. 

OTITIS EXTERNA (CONTINUED), NARROWING OF THE AUDITORY 
PASSAGE, OK MEATUS AUDITORIUS EXTERNUS. 

Consequences of the Affection, Prognosis, Treatment, Vesicants, 
Cataplasms, and Drops for the Ear to be avoided. — Slit and 
Circular Narrowing of the Canal, Exostoses and Hyperostoses. 

Gentlemen — In the course of long standing otorrhoea, poly- 
pous growths are very apt to be formed, which tend to an in- 
crease of the secretion of the ear, and often mingle blood with 
it. A number of other pathological changes may arise, inas- 
much as the pus, which remains in the canal for a long time, 
decomposes and irritates the tissues, and brings them into an 
inflammatory condition. The membrana tympani very often 
ulcerates ; and the morbid tissue, till now confined to the outer 
portions, extends to the cavity of the tympanum, and the inner 
part of the ear. We will later give a more careful and con- 
nected notice of the subject of discharges on account of its 
great importance. Here, however, I only call your attention 
to the fact, that not only purulent processes of the inner and 
middle ear, but also those which are confined to the outer ear 
can produce those unpleasant consequences so well known to 
you as resulting from otorrhoea. I have to call to your attention 
the neighboring, relative relation between cutis and perios- 
teum, of which we have just spoken, and to bring to your 
mind more exactly the situation of this canal. As you 
know, the upper wall of the bony portion of the auditory 
canal forms also a part of the floor of the cerebral cavity, 
and that this bony wall is always slight, porous in struc- 
ture. Sometimes the upper wall is thinned even to trans- 
lucency, so that there is only a thin layer of bone between 
epidermis and dura mater. Posteriorly the auditory canal is 



NARROWING OF THE AUDITORY PASSAGE. 69 

separated from the fossa sigmoidea, in which the greatest blood- 
vessel of the dura mater lies, the sinus transversus, even in 
adults, by a layer of bone only a few lines in thickness, which 
only presents on each surface a small quantity of compact tis- 
sue, in other parts is made up of cellular structure, such as 
obtains in the mastoid process. It must be evident that 
the adjacence of such diploetic bodies to the sinus trans- 
versus and the brain, can produce very important results 

From Troltsch's " Anatomy of the Ear." 



Squ, 



Yertical section of the bony auditory canal (right side), made near the membrana 
tympani, and almost parallel with it. 

M. A. E. — Meatus auditorius extemus. 

C. Gl. M. — Articulation inferior maxilla. 

Sq. — Inner surface of squamous portion of temporal bone. 

The dura mater has been removed, we see the elevations and depressions of the 
inner surface of bone. 

P. M. — Mastoid process. 

F. S. — Fossa sigmoidea, in which the sinus transversus runs. 

in the course of inflammatory and purulent processes in the 
auditory canal, and that such affections, with and without par- 
ticipation therein of the cavity of the tympanum, without per- 



70 NARROWING OF THE AUDITORY PASSAGE. 

f oration of the membrana tympani, without caries of the ossi 
cula auditus, may be very dangerous to life in their results. 
Toynbee speaks of such a case of inflammation of the auditoiy 
canal, which, with no perforation of the drum, or ulceration of 
the bones, went on to meningitis purulenta. 

In two cases in which I made post-mortem sections, accom- 
panied of course by other changes in the deeper parts of the 
canal, there were fistulous passages leading from the posterior 
wall of the auditory canal, through the mastoid process to the 
sigmoid fossa ; and in the one case, where there was a developed 
thrombus in the transverse sinus, the destruction of the throm- 
bus began when the bony fistula opened. 

These anatomical considerations are doubly worthy of notice 
in children, when the bony wall of partition from the brain is 
very thin and porous, and when there are plentiful openings for 
blood-vessels, which lose themselves in the bone substance, 
and communicating with branches coming from the dura mater 
Now the purulent discharges from the ear are very common 
in childhood, and are paid very little attention to by physi- 
cians and surgeons, when occurring in young children, but left 
to themselves unless some especial symptoms call attention to 
it. Even so little is this cellular space, as well as the blood- 
vessels of the brain in such contiguity to the ear, observed in 
post-mortem examinations, and it may sometimes have occur- 
red that the true cause is overlooked, which nnder form of 
meningitis, pleuro-pnenmonia, typhoid or pycemic condition, led 
to a fatal result. Never then omit in the diseases of children, 
when the importance of the symptoms is so uncertain and 
doubtful, to look by the sick-bed, and on the post-mortem table? 
at the possibility of the origin of the trouble in the ear. 

The Prognosis of Otitis Externa necessarily varies accord- 
ing to the exciting causes. An idiopathic inflammation of the 
auditory canal, or one produced by no extraordinary means, 
allows a favorable prognosis, if the disease be comprehended 
and appropriately treated. The secondary form, occurring in 
the Exanthemata, often results badly, becanse, in the danger 
of the constitutional disease, which may be great, threatening 
life, the ear trouble is either not carefully observed or entirely 
overlooked. 

The more the membrana tympani is attacked with the in- 



t NARROWING OF THE AUDITORY PASSAGE. 71 

flammatorj process — and this is often the case in the acute Ex- 
anthemata, and there is an acute inflammation of the cavity 
of the Tympanum — the less shall we be able to avoid a perfora- 
tion of the membrana tympani. However, when other circum- 
stances are favorable, this perforation is not so extremely seri- 
ous, and can always be remedied by a new formation. The 
Prognosis is much more unfavorable if the process has existed 
for some time, and important changes have already occurred, in 
other words, in chronic Otitis Externa. As is seen fro uT our 
remarks, each Otorrhoea must be considered, viewed by itself, 
as a serious matter, with certainty dangerous to the ear; for we 
cannot be certain as to how much part the adjacent parts, viz. 
the bones of the ear, will take in the process ; and the progno- 
sis in every chronic Otorrhoea will be considered uncertain and 
doubtful, although the form which is confined to the external 
ear is generally healed, the discharge gradually ceases, and the 
hearing returns to a certain degree. 

The Treatment of Otitis Externa in the beginning of the 
acute form, as well as in each subacute branch of the chronic 
form, is an unmistakably antiphlogistic one. The patient 
should remain in-doors, be placed on light diet, and take a 
saline cathartic. Leeches are almost always required, and 
those, according to our previous advice, should be placed before 
and on the external meatus. As a rule, from two to four will 
be enough ; and occasionally their application will require to 
be repeated, if the pain and other inflammatory symptoms con- 
tinue. Next to leeches, nothing so quiets the pain as often fill- 
ing the ear with lukewarm water, leaving it in the ear, the 
patient lying on the other side from five to ten minutes. If 
purulent discharge has commenced — Otorrhoea — we must be- 
fore all things secure the removal of the secretion ; and to 
this end the ear should "be syringed three or four times 
daily, which performance is generally extremely pleasant to 
the patient, if the temperature of the water be properly regu- 
lated, and the injection be done slowly. In the intervening 
time the patient should lie on the affected side as much as possi- 
ble, in order that the secretion may have a free exit ; and this 
may be assisted by long strips of thin lint or linen placed in 
the ear. This last suggested appliance is a good one to be used 
in all cases of discharge from the ear. For the diminishing of 



72 NARROWING OF THE AUDITORY PASSAGE. 

the secretion you may use astringent lotions, weak solutions of 
alum, acetate of lead, sulphate of copper or zinc, with which 
you fill the canal, after it has been cleaned. The same solu- 
tions, gradually increased in strength, should be used in the 
chronic form of the disease, and should be retained as long as 
possible in the ear. These should be always warmed, never 
cold ; when dropped in, a small reagent-glass may be used for 
warming the lotion. "When there is only a slight amount of 
discharge, we may remove it by means of a camel's hair 
pencil. 

Shall we consider, now, the remedies which I do not use or 
recommend in this affection. First, then, there are Blisters and 
pustule-causing Salves, which are applied by aurists indiscri- 
minately over the mastoid process. In acute inflammation 
they increase the pain and irritation ; and in children and per- 
sons with a delicate skin, produce an Eczema in the region of 
the ear. In chronic cases, however, they will seldom do harm, 
but no manner of good. "We have had full opportunity to col- 
lect experience on this point, since almost every patient with 
chronic affection of the ear has been blistered. Who can deny 
that in a case of Otorrhcea, a long continued discharge behind 
the ear is a real source of trouble and of un cleanness ? Dry 
heat, applied by means of warm cloths, or warmed cotton, as 
is commonly used in Germany, in stilling pain in the ear, di- 
minishes somewhat the pain ; but it returns in a greater degree 
so soon as you discontinue its use, and in this way the inflam- 
matory condition is considerably increased. The moist appli- 
cations, such as poultices, are common among aurists. I have 
made use of them in my former practice, but have now 
nearly discontinued the habit, only making use of Cataplasms 
in the case of Furuncles, or entirely superficial diffuse inflam- 
mation of the canal. Nothing stills the severest pain in the 
ear so quickly, and exerts such quieting influence ; no remedy 
shortens the painful congestive stage as the application of 
poultices, in the various forms of Otitis ; since it quickly pro- 
duces exudation and discharge, and with it cessation of tension 
and pain. There can be no question as to the truth of this 
experience. 

In spite of all this, I warn you against their use in all deep- 
seated inflammatory processes in the ear, because there is 



NARROWING OF THE AUDITORY PASSAGE. 73 

nothing so adapted to produce profuse and wearying discharges 
as poultices. 

When I compare the results of my present practice with 
my former, when I commonly used poultices, I perceive a 
very marked difference in that now a perforation of the mem- 
brana tympani seldom occurs, and the following discharges 
show themselves much less obstinate. This is a fact well 
worthy of notice in all inflammations, where the membrana 
tympani is affected in any way ; and I am of the opinion that 
the number of cases of otorrhcea and affections of the temporal 
bone would be sensibly diminished, if all inflammations of the 
ear were not so indiscriminately treated by the application of 
cataplasms. 

The often filling the ear with warm water, which is a clean 
and interrupted cataplasm, will greatly diminish the pain, if 
not quite as much as the application of a poultice to the whole 
region of the ear ; and from it I have never seen any such 
excessive softening and relaxation of tissues, such as followed 
from the generally practised method. 

If we refer to the analogous condition of affections of the 
eye, for a proper estimation of this practically important 
question, we know that in blennorrhoea of the conjunctiva, the 
warm treatment produces very quickly destruction of tissue, 
and we can excite an intense form of blennorrhoea, by the use 
of cataplasms ; for instance, in an old case of pannus, warm 
poultices produce almost the same effect as inoculation with 
blennorrhagic secretion. 

Finally, as to the dropping in of warm oil, which is practised 
by some aurists. It has no kind of advantage over the drop- 
ping in of warm water ; on the contrary, the positive disadvan- 
tage, that oil is a kind of foreign body, an adhesive substance, 
which is not fitted to bring into contact with an irritated sur- 
face. Glycerine is better, not being adherent, and is soluble 
in water, so that it can be removed by syringing. However, 
simple water does the best service. 

Before we leave the external auditory canal, we have still to 
consider a number of circumstances, which may leave different 
degrees and different kinds of contraction, or narrowing of the 
external auditory canal. The most common is the slit-shaped 
narrowing of the cartilaginous portion. Here at the entrance 



71 NARROWING OF THE AUDITORY PASSAGE. 

of the canal, the anterior and posterior walls may lie close 
together, and lose the oval lumen, becoming simply a fissure 
or slit, or may even fully disappear. I have only observed 
this form in the case of old people. In one very marked case 
which I observed during the lifetime of the patient, and also 
after death, in a section of the parts, the dense fibrous tissue 
which forms the upper and posterior portion of the auditory 
canal, was in a condition of extreme flaccidity, and sank towards 
the anterior wall. It appears to me, that such a flaccid condi- 
tion of the fibrous tissue is the principal reason for this narrow- 
ing of the canal. It is a quite frequent condition, and often 
goes on to an entire closure of the passage, and a consequent 
diminution of the sharpness of hearing. The normal removal 
of the cerumen is rendered difficult by this change ; and an 
accumulation easily takes place, which is especially apt to 
happen in old persons. Persons whose hearing is impaired 
from such a cause, will hear better, as soon as the cartilage is 
pulled back or a speculum introduced. 

The wearing of such a formed cylinder in the ear, one 
which the patient can himself introduce, will be of service. 

Such forms of senile deafness, of a high degree, are however 
rare. I have seen but two others which pushed the anterior wall 
backwards, produce the same result. The view of Larrey, the 
father, that the loss of the molar teeth and the thereby changed 
position of the under jaw, caused the cartilaginous walls to fall 
together, is manifestly incorrect. 

A ring-shaped narrowing of the auditory canal occurs occa- 
sionally in consequence of a thickening of the skin, with or 
without otorrhcea. In one case it seemed to be the result of 
repeated furuncles, which appeared only in one ear. It is 
most commonly produced by chronic eczema, which sometimes 
so thickens the integument as to fully close the canal. This 
condition is best treated by the ordinary astringent applications 
for eczema ; astringent lotions, ointment of zinc, or red oxyde 
of mercury. In one case, the thickening was so great, that 
the auditory canal could scarcely be entered with a thin 
sound. Compressed and graduated sponge gradually widened 
it, so that the parts could be examined with a speculum, 
and the chronic otorrhcea interna could be treated from 
without. 



NARROWING OF THE AUDITORY PASSAGE. 75 

Three forms of narrowing occur in the bony portion of the 
canal. The one most common, but never very extensive, 
consists of an abnormal lying inwards of the anterior wall, 
close on to the membrana tympani. It occurs in every time 
of life. 

When this condition of the auditory canal is present, we are 
not able to see the most anterior and lowest portion of the 
membrana tympani, even by pulling the auricle very far back, 
and this hindrance to a full view of the membrana tympani, 
so far as I know, is the only influence which is exerted by this 
deviation from the normal condition of the canal. 

Exostoses of the auditory canal occur much more rarely, 
round hard elevations varying in size, which are either covered 
with white, or red, and thickened integument. I have always 
found them on both sides, generally more in one canal than 
the other, seldom on the anterior wall, or adjacent to the 
membrana tympani ; still I have observed no case in which 
they impaired the efficiency of the canal. Toynbee describes 
a number of such cases as existing on the anterior wall, and in 
some cases there was appreciable narrowing of the canal on 
their account. He considers their presence as evidence of a 
rheumatic or gouty diathesis. In all my observations, the 
cases occurred in men who were free livers, without, however, 
any arthritic symptoms ; and I have seen these little elevations 
at the beginning of the bony part of the canal, only as accident- 
al coincidences in declared catarrh of the cavity of the tympa- 
num. The contact with the sound developed great sensitiveness. 
Wilde observed one case of almost complete closure of the 
auditory canal, by means of an exostosis, which had its origin 
in the posterior wall. There were also two small exostoses in 
the other auditory passage. 

As there were evidences of progressive inflammation, he 
applied leeches to the meatus, and gave small doses of bichlo- 
ride of mercury internally, by which treatment they were 
diminished in size, and the hearing perceptibly improved. 

Toynbee observed a decrease in size in one case, after the 
use of a solution of nitrate of silver, and recommends the use 
of iodine internally and externally in such cases. 

Hyperostoses of the auditory canal are similar in their 



78 NARROWING OF THE AUDITORY PASSAGE. 

symptoms to the exostoses. These remain often after chronic 
otorrhoea, or spring up after this affection. In these cases, we 
have generally to deal with an all-sided, uneven narrowing of 
the auditory canal. The integument is generally found in a 
reddened condition in these cases. 



LECTURE VIII. 

INFLAMMATION AND INJURIES OF THE MEMBEANA TYMPANI. 

Affections of the Membrana Tympani very common, but seldom 
occurring alone and uncomplicated. — Acute and Chronic My- 
ringitis, Lacerations and Perforations of the Membrana. — Seve- 
ral Gases of Fracture of the Handle of the Malleus. 

Gentlemen — Affections of the membrana tympani occur very 
frequently, and this we would infer from its position and 
anatomical relations. It forms the partition wall between the 
auditory canal and cavity of the tympanum ; it can therefore 
be considered as belonging to both parts, and takes part in the 
affections of each of them. Moreover, tissue from either side 
is extended upon its surface, on the outer side from the auditory 
skin, a covering of skin and epidermis, and on the inner a 
continuation of the mucous membrane of the cavity of the 
tympanum, or middle ear ; all the vessels and nerves of the 
membrane -runm these two surfaces, while the middle layer has 
neither. This gives an additional reason, why the membrane 
should participate in the affections of the adjoining parts. We 
remember also that three of the most important tissues of the 
animal system are found in this membrane — the skin, 
mucous membrane, and fibrous tissue, hence pathological 
changes are very common in the part, and they seldom occur 
alone ; the membrane receiving, as we have seen, its blood and 
nerve supply from the adjoining parts, it is scarcely possible 
that it should be affected alone. It receives the inflammatory 
process from them, and in turn when it is first attacked 
communicates it. In chronic cases, we are almost unable to 
tell which was the part first affected, the membrane or cavity 
of the tympanum. 
I do not 'agree with the most authors, when I deem the exist- 



78 INJURIES OF THE MEMBRANA TYMPANI. 

ence of a true uncomplicated inflammation of the membrana 
tympani to be rare. I am constrained to this view, however, 
from the observation of a considerable number of patients ; 
made, as far as I am able, in an impartial manner. The anatomi- 
cal description of the parts involved, as well as the history of 
the cases in the text books, when they are carefully examined, 
also sustain this view. These present the symptoms of a 
diffuse inflammation of the auditory canal, or an acute or 
purulent catarrh of the cavity of the tympanum, in either of 
which processes it is easy to see that the drum of the ear will 
readily enough be involved. As a rule, we may by no means 
believe from the descriptions, that the membrana tympani was 
first and alone attacked. 

Myringitis* may occur in an acute and chronic form. The 
acute form, in the cases which I have observed, always occurred 
suddenly and in the night, generally after exposure to cold, 
and it could be generally traced to its cause; often after 
cold bathing, and accompanied by severe pain, increased by 
laying the affected ear on the pillow, and accompanied by a 
feeling of fulness, insensibility, and heaviness, and almost 
with a very great roaring sound in the ear. 

These symptoms, with infrequent interruptions, last from 
twelve hours to three days, and cease so soon as the auditory 
canal becomes moist, and a gradually developed discharge from 
the ear begins. In one case the pain ceased after a sudden 
attack of haemorrhage from the ear, which, according to the 
patient's account, was to the extent of a table-spoonful of blood. 

Objective Symptoms. — In the beginning of hyperemia of the 
membrana tympani, it appears as if it were artificially injected. 
There are not only three large vessels running along the han- 
dle of the malleus from above to the central most concave por- 
tion of the membrana tympani, called the umbo, and radiating 
from this point, but there are also vessels on the periphery, 
running to the centre, and connected on all sides with vessels 
of the canal. As a consequence of the infiltration of the epi- 
dermis, the shining appearance of the membrana tympani is 
soon lost, and its external surface becomes dull like glass that 
has been breathed upon. 

* So named by Linke and Wilde. 



INJURIES OF THE MEMBRANA TYMPANT. 79 

The handle of the malleus, which in a normal condition may 
be seen as a yellowish white stripe in the middle of the mem- 
brana tympani, is not to be seen at the same time, the mem- 
brane appears more flattered. In later stages the epidermis is 
lifted up in little lumps or lamellae ; and the corium, or true 
skin, is red, swollen, and loosened, and covered with a thin secre- 
tion. The auditory canal, which in the beginning of the attack 
remains entirely normal in the neighborhood of the drum, 
becomes injected very quickly. In some cases which I observ- 
ed, the process went on to ulceration, and perforation of the 
membrana tympani. In one case to a kind of subcutaneous 
ecchymosis. In another I observed on the posterior and upper 
edge of the membrana tympani, a swelling about as large as a 
pea, yellow, soft, and tender, touching which with the sound 
caused severe pain. The little elevation in the membrana 
tympani, protruding its surface into the auditory passage, I 
regarded as an abscess formed between its layers. This de- 
creases gradually with the subsidence of the inflammatory pro- 
cess. Under favorable circumstances the generally slight amount 
of discharge from the ear gradually ceases, the redness and 
infiltration disappear, and it is again covered with epidermis. 
It always, however, remains for some time dull and flat in 
appearance. The handle of the malleus, so distinctly to be 
seen in a normal condition, is not now so distinct in conse- 
quence of the thickness of the layer of cutis ; consequently we 
are able to verify an infiltration into the membrane long after 
its occurrence. I have observed these cases as only occurring 
in one ear. Chronic inflammation of the membrana tympani 
is observed more commonly than the acute. It is of a mild 
form, with very little formation of pus. Severe cases are 
always complicated with inflammation of the external audi- 
tory canal, so that we have to deal with a case of otitis externa, 
or it is extended with ulceration and perforation of the mem- 
brana tympani to the middle ear. Single uncomplicated chro- 
nic inflammation of the membrana tympani develops itself 
with so few subjective symptoms, that the patient first becomes 
aware of it in a marked dulness of hearing. The pain is gene- 
rally so slight and transient, and the affection is so little dis- 
turbing, that it may exist for years before any medical aid is 
sought. 



80 INJURIES OF THE MEMBRANA TYMPANI. 

In examining the external auditory passage we find no 
changes, except a partial softening of the epithelial covering 
in the immediate neighborhood of the membrana tympani in 
consequence of the adhesion of secretion. The secretion is 
generally small in quantity, quite consistent, with an offensive 
smell ; it Covers the membrana tympani, and is always on the 
adjacent parts in the form of crusts. The drum, even when 
there is no secretion from it, always appears dull and hazy, so 
that we can only just make out the handle of the malleus, and 
its processus brevis ; the epidermis, but only in certain points, 
generally posteriorly and above, is removed, and the spots are 
red and swollen. The remainder of the tissues appear vari- 
ously yellow or grey in color, occasionally thin, and varicose 
veins running through, which are generally found on the peri- 
phery. Polypi may be developed from these small swellings, 
spoken of above, and the purulent discharge is often only from 
these. 

The prognosis in the acute form is very good, if the patient 
be properly treated. The purulent discharge soon ceases, and 
the pain does not return. Recent perforations heal quite rea- 
dily, when there is no purulent catarrh of the middle ear con- 
nected with it. The thickening of the membrane gradually dis- 
appears, and the hearing is restored. Under favorable circum- 
stances scarcely a vestige of the disease remains. On the other 
hand, if the disease be neglected, if it be treated with poul- 
tices, or with irritating drops for the ear, the membrana tym- 
pani will remain perforated, and the otorrhcea easily become 
chronic, the purulent inflammation will extend itself more and 
more on all the other parts, and all the consequences of a chro- 
nic otitis can develop themselves from a simple myringitis. 
We shall see further on, what an importance chronic otitis has 
for health and life. 

In chronic myringitis the prognosis is much less favorable, 
for it is only by a year-long treatment that we are able to re- 
strain the secretion, and even then there will exist a certain 
tendency to relapse. Furthermore, the pathological changes, 
especially the thickening of the membrana tympani, are gene- 
rally so great, as not to lead us to expect much from the im- 
provement to the hearing. 

Treatment. — A very great deal here is identical with that of 



INJURIES OF THE MEMBRANA TYMPANI. 81 

otitis externa. In acute myringitis in connection with local 
blood-letting, you will give cathartic doses of calomel and 
jalap. Poultices are especially not to be employed here, but 
warm water slowly and carefully poured into the ear, accord- 
ing as there is pain felt in the part. If exudation has occurred, 
you should daily cleanse the ear by careful syringing, and 
afterwards drop in a mild astringent, and of these I give the 
preference to acetate of lead. In cases of long duration of the 
treatment, when the discharge becomes chronic, the remedies 
will be often varied. Vegetable astringents do not appear to 
me as efficacious as mineral. Under this treatment the puru- 
lent discharge will cease, and a quite extensive perforation will 
heal. For the remaining thickening of the membrana tympani,. 
tr. iodine or an iodurated salve should be rubbed behind the 
ear. If there is no purulent discharge present, and there has 
been none for some time, we can use stronger vesicants — nitric 
acid, croton oil, which in the beginning should be dilute, and 
gradually increased in strength. I have sometimes seen good 
results in superficial thickening of the membrana tympani from 
strong solutions of bichloride of mercury, from one to four 
grains to the ounce. The pain of such an application is some- 
times very severe, and we must be very careful that none of 
the fluid be collected together on the anterior and lower por- 
tion of the membrana tympani, where it would readily perfo- 
rate it, and you must never undertake such a treatment when 
you do not always have the patient under your eye. (The 
counter-irritation may be continued for months, and a consti- 
tutional treatment, the administration of mercury in some alter- 
ative form, given to the extent of just touching the gums, 
and then followed by iodide of potassium. The German aural 
practice, although I believe, on the whole, the best, is very 
much inclined to lightly esteem constitutional treatment in 
diseases of the ear. Kramer goes to a great extent in his ideas 
is to the entirely local character of the diseases of the ear, and 
jcouts the idea of any alterative treatment. Some diseases of 
;he ear require constitutional treatment, and among them chro- 
lic myringitis, just as certainly as iritis. It often depends on 
i syphilitic diathesis, and notwithstanding late and fashionable 
cachings, I believe that the power of mercury will again be 
universally acknowledged.) We have now to speak of injuries- 

6 



S2 INJURIES OF THE MEMBBANA TYMPAKI. 

to the membrana tympani; these are quite common, as we 
would infer from its delicacy of structure, and its susceptible 
position for external impressions. These injuries are generally 
ruptures, occurring from blows, a box on the ear, etc., or from 
explosions. I have seen old and recent rupture of the mem- 
brana tympani, the latter accompanied by otorrhcea, which were 
owing to a box on the ear, received at school. A short time 
ago a student presented himself to me, who had received a 
slap on the ear in a joke, and since which he had felt a slight 
pain in the ear. No discharge had occurred. The membrana 
tympani showed a rupture parallel with the handle of the mal- 
leus, running its whole length. The edges of the wound were 
reddened, and covered with blood. The posterior half severe- 
ly injected, the anterior normal, hearing considerably dimi- 
nished. 

It has been denied, but improperly, that rupture of the 
membrana tympani may occur from the explosion of cannon. 
I have seen one recent case, and several old ones, which with- 
out doubt were thus caused, and when linear perforations or 
cicatrices were to be seen. The course of these is almost 
posterior to, and parallel with the handle of the malleus. 
Such cicatrices appear as greyish white, sometimes slightly 
bronzed lines. 

Yery many cases of deafness occur among artillerists who 
have served a very long time, and they always date it to a 
moment, when standing near a cannon in the act of discharg- 
ing, they felt a heavy blow and pain in the ear towards the 
cannon, and blood escaped from the ear. In some cases I 
found the hardness of hearing so great, as to imply that still 
more serious injuries had taken place. It is well known that 
rupture of the membrana tympani often occurs in fracture of 
the base of the skull. Wilds relates two cases of suicide by 
hanging, when the membrane was ruptured. This is not 
always true, however; for I once made a section in a case of this 
kind, where the membrana tympani was uninjured. The 
membrane is sometimes perforated by means of sharp-pointed 
instruments, which are pushed into the ear, in order to relieve 
irritation or itching. Women often use knitting needles for 
this purpose, and I have seen cases which were brought about 
in this manner. A careless probing of the ear by the surgeon 



INJURIES OF THE MEMBRANA TYMPANI. 83 

may also produce the same result. It must be evident to you, 
that you should not put a probe into the ear deeper than you 
can illuminate it, and thus have the eye for a guide ; without such 
a precaution, much injury may be done with the probe, or an 
instrument of similar character, where the surgeon endeavors 
to satisfy himself as to the condition of things without ocular 
inspection. 

In cases of injuries in explosions, such as occur in artillerists, 
severer injuries, haemorrhages, and lacerations of the deeper 
parts occur. These require careful observation, and treatment 
according to general therapeutic principles. "We will speak 
of this again when we come to nervous deafness. To this 
place belong the few observed cases of fracture of the handle 
of the malleus. Meniere* speaks of such a case occurring 
in a gardener, who accidentally had a twig of a pear tree 
thrust in his ear. A very extensive laceration of the membrana 
tympani took place, and the little bones of the ear could be 
plainly seen and their movements distinguished. This re- 
markable injury healed of itself, without any especial treat- 
ment. I myself saw a case of united fracture of the manu- 
brium mallei. 

A wine merchant thrust a pen handle, which he held in his 
hand, into his ear, in consequence of knocking his elbow against 
an open door. The severe pain caused him to faint, and he 
did not recover for some minutes. Cold water was immediately 
put in the ear, and he could not tell whether blood flowed 
from it or not. After that time he heard poorly from the 
injured ear, and suffered from noises in it, more especially if 
he lay on that side. "When I saw the case, one year later, the 
peculiar slanting position of the handle of the malleus was 
very striking, it appearing, also, uncommonly thick and promi- 
nent at a point immediately under the processus brevis, and 
from this point out turned on its axis. In short, it made the 
appearance of a united fracture of the handle of the malleus. 
Hyrtl\ described such a case, which he found in the ear of a 
prairie dog {arctomys ludovicianus), which had a very similar 
appearance, and was also, as in the above case, immediately 
under the neck of the malleus. 

* G-azette Medicale de Paris, 1856, No. 50. 

f Wiener Mediciniscber Wochenschrift, No. 11, 1862. 



84 INJURIES OF THE MEMBRANA TYMPANI. 

He decided that such an injury was not impossible to this 
animal, which is a relative to our marmot, lives in caves or 
holes under the ground, and whose membrana tyinpani,in conse- 
quence of the shortness of the auditory canal, is very external. 
(Professor Joseph Hyrtl, teacher of anatomy in the Yienna 
University, has a very extensive collection of the little bones 
of hearing, and of the internal ear, of the mammalia. He 
received a medal at the last London Exhibition ; but his works 
and lectures have done more than can any medals to give him 
the great reputation which he so deservedly bears.) 



LECTURE IX. 

THE APPLICATION OF THE CATHETER TO THE EUSTACHIAN TUBE. 

The History of the Subject. — Common Errors in the Use of the 
Catheter. — Method of Introduction. — Accidents which may 
occur. — Spasms of the (Esophagus. — Emphyzema. — Haemorrha- 
ges. — Description of the Catheter. 

Gentle^len — Now that we have finished the subject of the 
affections of the external ear and of the membrana tympani, 
we may turn to-day to those of the middle ear. These may be 
comprised in the cavity of the tympanum, the Eustachian 
canal or trumpet, and the mastoid process. In order to know 
the condition of these parts, deeply lying as they are, we must 
have some means of approaching them, and this we have in 
the Eustachian catheter, introduced from the entrance of the 
opening into the pharyrx. The mode of introduction of this 
instrument, and its use in practice, will be the subject of the 
present and the following lecture. It was more than a century 
and a half after the discovery of the connexion of the ear 
with the throat, by Bartholomeo Eustachio, in 1563, that any 
practical result of the discovery was had. It is a well known 
fact that it was a layman who first made use of the discovery — 
Guyot, the postmaster at Versailles, who, in 1725, promulgated 
to the Paris Academy the idea of injecting the middle ear, by 
means of a curved metal catheter, which he introduced through 
the mouth. He is said to have been cured of a deafness by 
this operation, which had continued for some time. Archi- 
bald Cleland, an English army surgeon, in 1741, without as it 
seems knowing anything of Guyot, proposed the introduction 
of the catheter through the nose, and this method is the only 
one which is practicable, and which is now used. 

Whosoever expects to practise aural surgery, must be able 
to use this instrument, as we can by no means find a substitute 



36 APPLICATION OF THE CATHETER 

for it, or dispense with it altogether. You will find a general 
conviction among surgeons, that the introduction of the Eus- 
tachian catheter is a very difficult and painful operation. 
Yon, yourselves, however, have seen that such is not the 
case, and that it is only true in exceptional and rare cases. 
On the contrary, this operation is an easy and painless one, if 
we but understand the anatomy of the parts, and the method 
of performing it, dependent upon this, and practice will soon 
overcome all the little difficulties in the way of an easy intro- 
duction of the catheter. I use a silver catheter, bulbous- 
shaped at its curved end, with a ring in the straight extremity. 
This latter, by its position, gives evidence as to the exact situa- 
tion of the point of the instrument. "We must always, during 
the introduction of the instrument, keep a finger upon the 
ring, in order that the direction of the beak may be clear to 
us. The oiling of the instrument before introduction seems 
to me unnecessary. It is well to cause the patient to blow 
his nose before the operation, in order that slight tem- 
porary obstructions may be removed, and the canal some- 
what moistened. I show you all the steps of the operation , 
by means of a half head. (Picture of instrument, page 90.) 
"We introduce the bulbous-shaped, curved extremity of the 
catheter, with the point directed a little downward, into the 
inferior meatus of the nose, then quickly raise the whole in- 
strument, so that the ring shall be exactly on a vertical line, 
pushing carefully further in, on the floor of the nasal cavity, till 
the posterior wall of the pharynx be reached, touching the atlas. 
Then draw the catheter from J to I inch backwards, towards 
yourself, lift the outer end somewhat, and turn the ring, which 
has hitherto been on a vertical line, to one running upwards 
and outwards or opposite to the external ear. In some rare 
cases, the ring can only be made horizontal. It is well to sup- 
port the head of the patient during the operation, and that 
both surgeon and patient stand during it. The above de- 
scribed method is the one given by Kramer, and is undoubt- 
edly the best. It has been advised not to pass the instrument 
as iar back as the wall of the pharynx, but to attempt to turn 
the point of the instrument into the mouth of the canal, which 
is situated somewhat anterior. This method would seem 
shorter and more convenient, because we are not obliged to 



TO THE EUSTACHIAN TUBE. 87 

pass over the same way twice, but it is not so safe, while we 
cannot generally tell the instant when the instrument leaves 
the nasal cavity and enters the mouth ; it is much easier to feel 
one's way as above described, by passing the instrument fully 
back to the posterior wall, and then repass a portion of the 
route. The most common mistake in the introduction of the 
instrument is not withdrawing it far enough, thus causing the 
point to fall into the little fossa behind the mouth of the Eus- 
tachian tube. We may also, by a half conscious motion back- 
wards, in turning the instrument, push it into this fossa. This 
mistake is the less remarked in that the light motion of the ca- 
theter in this position gives about the same sensation as when 
it is in the mouth of the canal itself. If we blow through the 
catheter, when it is in this position, it is felt, not in the ear, but 
in the neck, and we hear a moist, fluttering sound, as when 
mucus is set in motion. Benjamin Bell, the distinguished 
Edinburgh surgeon, says that when surgeons claim to have 
entered the entrance of the Eustachian canal, they have only 
entered this fossa. This statement proves nothing more than 
that great men sometimes make great mistakes. It is true 
that this error of lodging the instrument in this fossa is a mistake 
often made, especially by those who have had little experience 
with the catheter. This is explained from the fact that there 
is no rule, as to just how far we shall withdraw the point of 
the instrument, after having reached the posterior wall of the 
pharynx, since the distance of the mouth of the tube from the 
vertebrae is different in different individuals. After some 
practice, however, this is no longer difficult. The introduction 
of the instrument into the mouth of the canal, in the case of 
children, is difficult because the mucous membrane is so apt to 
be swollen and tense. 

The ostium pharyngeum tuba?, is not so far back in the 
mouth as in adults, and the small undeveloped lips of the 
opening lie so far apart, that we often have trouble even on 
the cadaver of an infant, to put the instrument in the proper 
opening. In many cases it is well to draw down the upper 
lip of the patient with the finger, and thus make the entrance 
to the nose easier. As soon as the catheter has entered the 
nose, the direction of the instrument must be changed from 
downwards, to a straight one ; else we may get into the mid- 



APPLICATION OF THE CATHETER 

die nasal fossa, through which it is difficult to pass the instru- 
ment backwards, and it is quite often impossible to turn it 
here so that the point may enter the opening of the canal. 
The inferior nasal fossa, and floor of the nose, are by far less 
sensitive than the middle fossa, and is the only one through 
which the instrument should be introduced. Only in veiy 
rare cases is there any danger after once having fully entered 
the inferior meatus, of changing to the middle. If the cathe- 
ter has been properly introduced into the inferior meatus, it 
will form a right angle with a line drawn across the face ; if 
in the middle an acute. It is a rule, in introducing the instru- 
ment, that the bulbous end should incline downwards. 

If there are any impediments to this direction, we should try 
by gentle side motions to overcome them. The outer extre- 
mity of the instrument should be held lightly but still firmly 
in the hand. I have sometimes, in attempting to overcome 
some obstruction in the nasal canal, been obliged to turn the 
instrument directly on its axis, similarly to what is done in in- 
troducing the urethral catheter called " le tour du maitre." 
If we cannot then pass the instrument, or if it causes pain, we 
must chose another catheter, of another angle and calibre. I 
have observed more such hindrances on the left than on the 
right side, so that I would advise you to begin your examina- 
tions with the right side. 

Occasionally, but rarely, a case occurs where one side of 
the nose is impassable. This can 'occur in consequence of ab- 
normal narrowing of the inferior meatus, as well as from nasal 
polypi, and from a particularly oblique position of the nasal 
wall of partition. I found in the case of a young girl, the 
cartilaginous septum so abnormal in position as only to permit 
the passage of a very small sound. 

^ We can bring more deeply lying abnormal appearances to 
light, by means of the speculum and laryngoscope. In some 
cases where one nasal meatus is impassable, the Eustachian 
tube of this side can be entered from the opposite side, an 
operation that was thought to be impossible at one time. It is 
of course not so simple and safe as the direct method, but it can 
be done when necessary. 

The introduction of the catheter, however, is not hard to 
leara and practise, if the surgeon will but give a little time to 



TO THE EUSTACHIAN TUBE. 89 

it. Practise it first on the half head, then on the dead subject, 
then on yourselves. You are sure it is in the right position 
from the fact that, when introduced, it does not interfere with 
speaking or swallowing, that the point cannot be turned any- 
further up, and that the air blown in is felt to come upon the 
ear. If properly introduced, it causes no pain ; most patients, 
at the greatest, speak only of an unpleasant feeling ; of a tick- 
ling in the throat, while the operation is being performed for 
the first time. It is almost never experienced in a repetition. 
These unpleasant feelings occur at the first time, because we 
are dealing with parts that are scarcely ever touched. When 
there are natural hindrances to the passage of the instrument, 
abnormal narrowness of the canal, etc., the operation cannot 
be performed without pain, but these are exceptions. More 
inconvenience is caused when the instrument is introduced 
with uncertainty and want of skill ; although we very often 
have to deal with a membrane that is hyperaemic, and catarrh 
of the cavity of the tympanum is very often connected with 
catarrh of the pharynx ; yet this unpleasant sensation scarcely 
ever amounts to a pain, and it is only in cases of great irrita- 
tion that sneezing fits occur. The sensitive membrane soon 
becomes accustomed to the feeling of the instrument, and we 
can soon pass from a slender and small angled one to a larger. 
Sometimes it happens, especially in the first trial, in very 
sensitive and anxious patients, that a spasm of the muscles of the 
pharynx and palate occurs ; and the instrument, if not already 
in the mouth of the tube, is held fast, and prevented from any 
further motion, while from the severe pressure on the mucous 
membrane much harm is done. 

The surgeon should endeavor to quiet the patient, endeavor to 
persuade him to open the spasmodically closed eyes, and look 
calmly on him, while he lightly turns the catheter to the 
proper position. The patient must neither speak nor swallow, 
before the instrument is in the entrance to the Eustachian tube. 
The quieter and more confiding the patient, so much the easier 
is the operation for the surgeon. 

The more decided the surgeon is in his manner, the less time 
he wastes in telling what is about to happen ; the easier, 
especially with nervous patients, will the operation be 
performed. As to other accidents which may occur, there is 



90 APPLICATION OF THE CATHETER 

the so much feared emphysema of the neck, 
occasioned by air passing through a perfora- 
tion of the mucous membrane. I have seen 
two such cases, in both of which I had often 
introduced the catheter, and no unpleasant 
symptoms had occurred. 

We find on the cadaver erosions, and tri- 
fling ulcerations about the mouth of the tube, 
and these are not to be diagnosticated without 
the Ehinoscope, and can easily produce em- 
physema. It is very evident that such a 
delicate membrane, as we have here, can be 
very easily injured. These air tumors affect 
the swallowing, and are frightful to the 
patient. I have seen no further evil conse- 
quences. In one case all the symptoms 
disappeared in twelve hours, in another in 
twenty-four. One of the patients very naively 
remarked, that his neck felt like veal, that had 
been blown up by the butcher. TuvrJmU, in 
London, is said to have lost two patients, some 
twenty years ago, from the use of the Eusta- 
chian catheter. Even if the compression 
pump were too strongly filled, which he had 
intrusted to the patient, it is hard to see from 
the published account of the autopsy how the 
accidents occurred.* "We know how common 
a thing is hemorrhage from the nose, and that 
in some people it is induced simply by a severe 
fit of sneezing. We will not wonder, then, 
that the catheter is sometimes tinned with 
blood. This happens often enough, when not 
the slightest pain or inconvenience has been 
caused. If such bleedings return or continue, 
a solution of alum gr. ij., aquas |i. 3 can be 
snuffed up the nose, and this will probably soon 
check the disposition. An increased secretion 
of tears, often causing them to run over the 

* See M. Frank's Handbook of Aural Surgery, p. 173. 
Handbuch der Ohrenheilkunde. 




Fig 5. 



TO THE EUSTACHIAN TUBE. 91 

cheek, is often occasioned by the catheter, without, however, 
exciting any pain. . 

We should have several sizes of the instrument. In my 
opinion it is the angle of curvature rather than the degree of 
thickness, which should be varied. This is in order to accommo- 
date it for the variable width and height of the inferior nasal 
meatus, as well as for the variable distance between the posterior 
extremity of the nasal septum, and the mouth of the Eustachian 
tube. 

Three different sizes will be sufficient ; if made of solid silver, 
the curvature may be altered to suit each case. 

Elastic catheters are not so serviceable as silver, they never 
impart as sure a feeling to the operator as the metal ones. 
The nasal passage is more easily passed through by them, but 
the mouth of the canal is harder to be found, and we cannot 
set as strong a stream of air through such a tube as through 
one with solid walls. 



LECTURE X. 

THE USE OF THE EUSTACHIAN CATHETER AS A MEANS OF DIAG- 
NOSIS AND CURE. 

Auscultation of the Ear. — The Otoscope and Air-Bath. — Substi- 
tute for the Catheter. — Manifold Use of the Catheter in Aural 
Surgery. — Operation of the Air-Bath. — The Catheter a Vehi- 
cle for Communicating Gaseous, Fluid and Solid Substances 
into the Middle Ear. — Compression Pump. 

Gentlemen — After having learned the mode of introducing 
the Eustachian catheter, the question occurs, what is the value 
of its use, and in what cases can we employ it. A general an- 
swer may be made as follows. Its use is so to open the Eus- 
tachian canal and cavity of the middle ear that we may pro- 
duce an effect upon them by remedies, whose application is ren- 
dered possible. This by other means is not possible, except when 
the membrana tympani, and thus the middle ear is exposed. 
(Politzer, in Yienna, sometimes places a small tube in the nasal 
meatus, causes the patient to shut his mouth, and swallow, and 
while he does this, the surgeon blows through the tube, and the 
air must pass into the Eustachian canal, haying no other exit ?) 
We have first to speak of auscultation of the ear, first described 
by Laennec. Traite de V Auscultation mediate. Paris, 1S37, 
4 ed., vol. iii., p. 535. 

Auscultation gives us a great many hints as to the condition 
of the middle ear, as well as of the Eustachian tube. Sur- 
geons are apt to say that the ear is not accessible in a diagnos- 
tic as well as therapeutic view. Access to it, however, is far 
easier than in some other organs. If we wish, however, to 
auscultate the lungs, or heart, we simply place our ear on the 
chest, this is the mediate method, or by means of the stethoscope. 
In the ear, the thing is not so simple, and we need more appli- 
ances than these. "We must first introduce the catheter through 



USE OF THE EUSTACHIAN CATHETEK. 93 

the nose, and after we have excited an artificial stream of air, 
we can auscultate. To this end we blow air in from the mouth, 
or from an air-pump. The sound of the air can then be heard 
by means of the otoscope. Toynbee has given this name to the 
gutta-percha tube, which he presented in 1S53, in order to 
auscultate the sounds in the ear, when the patient closed the 
mouth and nose, and swallowed. The name and instrument 
are in the highest degree adapted to their purpose, and we avail 
ourselves of it, even to a still greater degree than the inventor. 
If a full stream of air pass through an 
Eustachian tube of normal size and nor- 
mal degree of moisture, it creates a sound, 
which Dtlau likens to the falling of rain 
upon a leaf, and therefore called " bruit 
de pluie." I would rather call it a knock- 
ing sound, anschlage gerausch, because we 
hear the stream of air passing on a dry, 
elastic membrane, — the drum, — and push- 
ing this somewhat outward. The sound 
passes through the otoscope, and seems to 
the examiner very near him. The patient 
will exclaim that the air is passing through 
the ear, whereas it has only entered it. If 
the mucous membrane be covered with the 
normal secretion, the sharpness of tone is 
somewhat mollified, softer, not to say 
moist. Sometimes this knocking, rapping 
sound, has something hard and dry in it. 
This is accompanied by a peculiarly dry 
appearance of the membrana tympani, 
Fl °- * and we are able to conclude that there 

is a want of mucous secretion, such as often exists, after an in- 
flammatory process has been going on, and also in old people. 
If the Eustachian tube has been obstructed through swelling 
of its membrane, the air enters, instead of in a full strong 
stream, in a thin and weak and interrupted one, often with a 
whistling sound, and it strikes most strongly on the membrana 
tympani, when the patient swallows. Frequently, you hear 
the air enter only during the act of swallowing. 




94 USE OF THE EUSTACHIAN CATHETER. 

; If during the air bath, for thus we designate the air passing 
through the catheter into the middle ear, we hear a rattling 
sound, we must distinguish if it be far or near from the external 
ear, that is, if in the Eustachian canal or middle ear, if it be 
present in the beginning of the operation or continue during 
it all. Very often such sounds are occasioned only by the 
accidental presence of a larger than ordinary amount of mucus 
about the entrance to the canal. The mucous glands are very 
numerous at the pharyngeal entrance, so that we can distin- 
guish their openings with the naked eye, and on the dead 
body we find a greater or less amount of mucus deposited 
here. We can often hear a very near whistling sound, if the mem- 
brana tympani has a very small perforation, and we will often 
find a drop or so of pus or mucus in the meatus, which has been 
driven through this hole from the cavity of the tympanum. If 
with the Otoscope we hear only a far removed and indistinct 
sound, we can refer it to various causes. The catheter may not 
be placed correctly, and then the patient will have a feeling as if 
the air passed in his throat and nose ; a reintroduction will 
produce quite another sensation. The catheter may, however, 
be placed properly, and yet no distinct sound, or none at all 
be heard. The end may be covered by a fold of mucous 
membrane at the mouth of the tube, which prevents the free 
passage of air. The tube may be obstructed by means of 
accumulated and dried secretion, occurring in the thickening 
and swelling of the mucous membrane, not to speak of the 
very rare occurrence of an adherence of its walls to each other. 
We may also have a similar auscultatory experience, when the 
cavity of the tympanum is filled with secretion, or its walls 
adherent, through the swelling of the opposite surfaces. All of 
these are conditions which we will speak of more fully later on. 
You will find that even with the greatest skill in the use of 
the catheter, and with the greatest amount of patience and intel- 
ligence on the part of the patient, much will remain in doubt 
after the first examination, and it will be necessary to repeat 
it again and again, in order to make a safe diagnosis as to the 
condition of the cavity of the tympanum, and the membrana 
tympani. The less certain and practised is the examiner, the 
less intelligent the patient, the less will the instrument reveal ; 
but this is true of all methods of examination in all diseases. 



USE OF THE EUSTACHIAN CATHETER. 95 

The use of the catheter not only furnishes to the ear many 
evidences of disease, but also to the eye. If we examine the 
membrana tympani during the entrance of a stream of air, we 
may observe a very different effect upon this membrane, even 
with the same stream. Now it will be moved very much, and 
in its totality, outwards ; now weakly and slowly ; again only 
in single parts, while others will remain immovable. These 
and other symptoms which are noticed on and behind the 
membrana tympani during the passage of air, we are only able 
to indicate here, because, when we come to speak of catarrh of 
the middle ear, they will have another importance. 

As has been said, the patients themselves generally feel the 
stream of air in the ear, or going out of it. This feeling of the 
patient, and the visible movement of the drum by the stream, 
are not always in equal proportion. Sometimes the patient 
does not feel the air at all, and yet the membrane is pushed 
outward. I remember a case, where the patient, whose state- 
ment I thought perfectly reliable, said that he never felt the 
air. passing on the ear, on one side, after two weeks of treat- 
ment, while on the other he had the usual sensation. Never- 
theless, the movement of the membrana tympani, on the 
side on which he heard nothing, was greater than on the 
other. This was a case of complete want of sensation, 
anaesthetic condition of the cavity of the tympanum and mem- 
brane. 

Many physicians, even some aural surgeons, think they can 
substitute for the passing of the catheter, the well known 
experiment of pressing the air into th<5 cavity of the tympanum, 
when the mouth and nostrils are closed. This is called the 
Yalsalvian experiment. In many individuals, especially those 
very deaf, it certainly costs more time and trouble to explain 
this method and teach it, than is necessary to introduce the 
catheter and inject air. Moreover, this substitute obliges us 
to rely on the patient's reliability of statement for our diagnosis, 
unless we examine the membrana tympani during the experi- 
ment, which we will not be able to accomplish except with 
intelligent patients. Further, we are taught no more by this 
experiment, than that the tube is open ; how it and the cavity 
of the tympanum are otherwise situated, we are not able to 
learn. Then, again, patients who are well acquainted with 



96 USE OF THE EUSTACHIAN CATHETER. 

this method, are not able to press air in, while a strong blowing 
through the catheter proves the permeability of the tube. 

This mode, then, as opposed to the introduction of the 
catheter, is much less valuable in diagnostic value, less practi- 
cal, and sometimes even leading to false conclusions. 

The introduction of the catheter as a diagnostic means, is 
still less displaced by the method which Toynhee in London 
recommended. Toynbee caused the patient to swallow, while 
he auscultates the ear with the otoscope. If the Eustachian 
tube is permeable, a peculiar cracking sound is said to be 
heard, which is not the case if it be closed. Toynhee himself, 
however, confesses that the sound is sometimes wanting, when 
we know by other means that the tube is permeable. In 
short we have only to read the testimony of the author (on page 
196, of his " Diseases of the Ear,") to convince ourselves, how 
unreliable for diagnosis, and little to be trusted, the method is, 
and how incorrectly Toynhee, who is so highly to be esteemed 
as a pathological anatomist, substitutes this for the use of the 
catheter. This method, however, has its uses. If we look at 
the membrana tympani while the patient swallows with his 
mouth and nose closed, we find a variable condition of the 
membrane. Now on its inferior segment, it moves outwards 
again, and more commonly, it is drawn inward on its lower 
portion, and pushed out above, and sometimes does not move 
at all, although the tube is permeable both for the catheter, 
and the patient's own pressing in of air, and these motions are 
sometimes perceived with this experiment, when the Yalsalvian 
experiment has had only a negative result. 

We should also mention a new aid to examination, which 
Dr. Politzer of Vienna has introduced, by no means, however, 
as a substitute for the introduction of the catheter. He intro- 
duces a gutta-percha stopper in the ear, in which there is fast- 
ened a horse-shoe-shaped glass air measurer ; a drop of colored 
fluid in this rises, and falls, according as the air in the cavity 
of the tympanum is thinned by swallowing, when the breath 
is held, or pressed upon by the Yalsalvian experiment. Politzer 
has shown that this method is of great use and importance in 
a physiological sense. It remains to be shown, if there be 
much of practical value in it.* 

* See Sitsung's Berichte Wiener Academic March, 1861. Gazette Medicale 



USE OF THE EUSTACHIAN CATHETER. 97 

However, if the introduction of the catheter, as a means of 
diagnosis, can be set aside, and avoided, there is still another 
point to be considered, and that is, — its therapeutic value. 

The Eustachian catheter is more important, by far, for the 
treatment of disease, than for diagnosis. In many cases we 
can diagnosticate catarrh of the cavity of the tympanum, from 
the appearance of the membrana tympani, without any cathe- 
ter, but we cannot treat it without its aid. Whoever does not 
use the catheter deprives himself of the single, reliable means, 
whereby the majority of deaf persons can be locally treated, 
and he must confine himself to constitutional treatment alone, 
which is of very little value in these cases. 

We often benefit the patient at the first use of the instru- 
ment, although we are merely using it for diagnosis and pro- 
gnosis. 

How then does the use of the catheter do good in the treat- 
ment of aural disease ? What therapeutic value has the instru- 
ment ? We will refer to facts which have been observed, and 
let these answer the question. 

If we examine the membrana tympani, while a strong stream 
of air is passing into the middle ear, we will see in all cases, 
where it is not met by hindrances, that the membrana tym- 
pani is more or less moved outward. We are not only able to 
hear the motion, but we can convince ourselves with our eyes, 
that this stream of air not only enters the cavity of the tym- 
panum, but that it also has a certain mechanical power. It is 
evident, that if there is such an effect on the membrana tym- 
pani, there must have been a considerable effect, while the 
stream was on the way. The walls of the Eustachian trumpet 
are not only separated from each other, but also all hin- 
drances in it and the cavity of the tympanum, such as mucus 
and pus, will be put in motion, and driven either into the mas- 
toid cells, or in the throat. This air-bath, if we may so desig- 
nate it, works as a cleanser of the Eustachian tube, and of the 
cavity of the tympanum, and restores the connection between 
the throat and the latter, if this has been interrupted. 

Moreover, since we can follow the process with the eye, and 
see the membrana tympani moved outward, we see that some 

de Paris, 1861, p. 398. Wiener medicinische Wochenschrift, 1861, No. 12, and 
1862, Nos. 13 and 14. 

7 



98 USE OF THE EUSTACHIAN CATHETEK. 

abnormal adhesions of this membrane mnst of necessity be 
stretched, and perhaps be loosened. This last named mecha- 
nical process on adhesions in the cavity of the tympanum, we 
have only to verify.* 

We learn from this that we quite often loosen a synechia in 
the cavity of the tympanum, in the cases where only one in- 
troduction of the catheter has been of great use in restoring 
hearing ; cases, which have hitherto been called accumulations 
of mucus in the middle ear. This above mentioned effect of 
the air-bath, which is quite common, because the adhesive pro- 
cess in the cavity of the tympanum is among the frequent of 
the pathological conditions in the ear, has been hitherto entire- 
ly overlooked by aural surgeons. This fact is only to be ex- 
plained by the neglect of examination, and the insufficience 
of the previous methods of illuminating the ear. We should 
never omit, after the air-bath, to examine the ear very care- 
fully, because we are thus enabled to see what effect we have 
produced, and on what anatomical consideration this improve- 
ment in hearing depends. Up to this time, all the observa- 
tions which have been made as to the effect of condensing or 
rarefying the air in the cavity of the tympanum, have been 
referred to the effect made upon the membrana tympani, as if 
it were not a mechanical law, that effects should be made in 
all directions where the stream of air passes. Politzer was 
the first to show the one-sidedness of this view, and he showed 
experimentally, that each effect of rarefying or condensing 
the air in the cavity of the tympanum must be produced not 
only on the membrana tympani, bnt also on both the fenestra?. 

Eepeated introduction of streams of air will remove a recent 
or commencing rigidity, can possibly break up an anchylosis 
of the stapes, and may restore the lost elasticity of the mem- 
brane of the fenestra rotunda. 

These adhesive processes occur very often in these parts, 
and their occurrence has great effect in diminishing the hear- 
ing, therefore the use of the catheter is very important. 

I may take this opportunity to speak of an objection, which 
older members of the profession make to the use of the cathe- 
ter. Many fear to use it, because they believe it is very easy 

* Vide VirchoVs Archiyes, voL 17, section 5. 



USE OF THE EUSTACHIAN CATHETER. 99 

to blow mucus from the throat into the cavity of the tympa- 
num, and thereby cause injury. I doubt not but that this first 
sometimes occurs ; but if we do not stop at a single blowing, the 
mucus will certainly come out again into the throat, or into 
the cells of the mastoid process, which lie on the same plane 
with the entrance into the cavity of the tympanum from the 
Eustachian tube. Consequently the course and power of the 
stream of air must be directed against it. I have never seen 
any injury produced from blowing air into the cavity of the 
tympanum, although I have certainly introduced the catheter 
25,000 times, and the air-bath through it. We should call to 
the recollection of these theoretical gentlemen, that the cathe- 
ter is much smaller than the entrance to the pharyngeal tube, 
and that consequently it is not tightly held by it, and there is 
always a large returning stream of air, in which will fall all 
the irritating moving bodies before the bony portion of the 
canal is reached. The tenacious mucus, which is in the throat, 
will certainly be oftener blown in the mouth than in the ear. 
There are other objections, such as that the catheter irritates 
the mucous membrane, a view which Toynbee also takes, but 
these are still less reasonable objections, and they have no 
force, until some one wishes to use the catheter, to whom the 
whole operation is perfectly obscure. We may say, that 
Raits remark may be applied here, when he sa} T s : " The prin- 
cipal objection of most opponents is want of dexterity in the 
use of the catheter." 

The effects of the catheter, which we have hitherto observed, 
are generally transient in their nature, or at least gradually 
diminishing in value. It is generally desired to secure a lasting 
influence on the affected membrane of the middle ear, for 
after the removal of the secretion, or the separation of the 
opposing surfaces, the mucous membrane will still remain 
affected. The local treatment is only possible with the 
Eustachian catheter ; it serves as a vehicle for introducing vari- 
ous remedies, which work directly on the tube and on the 
cavity. Such medicaments are either in the form of fluids, or 
of vapor or gases. I consider the injecting of fluid remedies 
into the middle ear, which is done so much by aurists, as use- 
less. If we consider the ascending course of the Eustachian 
tube, and its narrowness in some places, it is clear that a fluid 



100 USE OF THE EUSTACHIAN CATHETEK. 

can only be injected with a certain force. In this case, how- 
ever, the greater part of the fluid will be driven into the cells 
of the mastoid process, whose entrance lies at the same height 
with that of the tube, while another part will not set over the 
narrowest part of the canal, but go back into the throat. We 
cannot then saj with the least certainty how much of the fluid 
which we wish to inject will be found in the cavity of the 
tympanum, how much in the throat, and how much in the 
mastoid cells. Furthermore, we are not able to provide for 
the equal distribution of the fluid on the walls of the cavity of 
the tympanum, so that possibly a portion will not be touched 
at all, while another receives a strong dose. At any rate, that 
portion which does enter will be removed from the flat walls, 
and collected on the floor of the cavity, or in its various cran- 
nies, as for instance on the fenestra rotunda. The caustic 
remedies, such as a strong solution of caustic potassa, can very 
easily do great damage in those parts where they must speedi- 
ly collect. This may happen with the use of a very small 
number of drops, which aural surgeons generally confine them- 
selves to. If, however, we inject a large quantity, completely 
filling the middle ear, great damage can be done, on account 
of the softness of the parts. A case is related by a Venetian 
physician, in which severe effects were produced by such injec- 
tions. One patient was affected with vertigo for ten full hours 
after the injection of warm water into the cavity of the tympa- 
num. In another case periodical pain in the ear was added to 
the deafness. I advise you then, gentlemen, to make no injec- 
tions of fluids through the catheter. You will not be able to 
restrain their effects, or to be assured of any good, but you can 
do great harm to the patient, and Hippocrates says " Primo 
non nocere." If you wish to introduce remedies into the tube and 
cavity of the tympanum, according to my view, it can only be 
in the form of gases. It is true that the choice of remedies for 
the^ treatment of ear diseases becomes, therefore, rather 
limited^ but on the other hand, their application and effect has 
a certain safety. In the application of vapor through the 
catheter, we must remember that the ear trumpet, or^Eusta- 
chian tube, is very narrow for some distance, and that it is still 
more narrowed by a light apposition of the two Burfac 
further, that the stream will moisten the mucous membrane 



USE OF THE EUSTACHIAN CATHETER. 



101 



and cause it to swell. If we will be certain that the gases or 
steam that we use will reach the cavity of the tympanum, we 
must connect the apparatus for the manufacture of the gas 
with a pump, so that the vapor may be driven forward with 
a certain force. In a case of necessity we can use our own 
lungs, or a gutta percha bottle, as a means of pressing in 
the vapor. If one has to deal with many patients this will 
become very tiresome. I use a compression pump, not only 




Fig. 7. 

for the air bath, but also for the treatment with vapors 
and gases. My apparatus consists of a quite thick glass 
bell, 40 centimetres high, and twelve broad, which is fas- 
tened on a wooden support, by means of a strong measuring 
tub. There is connected with this a pump 20 centimetres 
long and 4 ctm. in diameter, which with its wooden support 
rests on the table. In the tube which connects the bell with 
the pump, there is a faucet which has an opening for the 
entrance of external air, and is besides perforated by a hori- 
zontal opening, through which canal the air pressed by the 



102 



USE OF THE EUSTACHIAN CATHETER. 



pump passes. The faucet for the regulation of the exit of air is 
on 'the top of the bell, and there is a gutta percha tube added 
to it, which leads the air into the catheter or heating appara- 
tus. The measuring tub at the bottom of the glass bell is 
fastened on by a screw, which must be air-tight, and this 
admits of removal for cleaning. I have tried very many appa- 
ratus, and I believe the one which I have just described as the 
best. * * This instrument is manufactured for 36 guldens, 
about $19.) As a contrivance for the generation of steam, I use 
a simple glass flask, which is placed on a sand bath, and heated 
by means of a spirit lamp. The cork of the bottle is bored in 
four places, one for the funnel-shaped glass tube to which a 
stopper is adjusted, one for a thermometer, and the remaining 




Fig. 8. 



two for the entrance and exit of the heated air, connecting 
respectively with the gutta percha tube from the pump and 
with the catheter. In order to steady the flask, an iron sup- 



USE OF THE EUSTACHIAN CATHETER. 103 

port goes from one of the legs of the stand, as seen in the plate. 
When there is no necessity for the regulation of the tem- 
perature only two holes are necessary in the stopper of the 
flask. 

A number of instruments are recommended for securing the 
catheter in its place, during the operation of pumping heated 
air or steam into the Eustachian tube. The best one is that of 
Rau's, modified, consisting of forceps, for holding the catheter, 
attached to a pair of spectacles. The forceps are fastened by a 
strong spectacle frame, by means of a movable slide with an 
adjusting screw. The forceps are spring instead of screw, as 
given by Rau, with wing-shaped extremities. 




Fig. 9. 

If the catheter has been fastened in its position by means of 
this forceps, the patient can speak or swallow, or even sneeze, 
without being in danger of displacing it. 

When you wish to give the air bath, place the patient near 
the table on which the pump stands, and either hold yourself 
the tube connecting with the catheter, or intrust this to the 
patient, and it will be the same when the heating flask is be- 
tween the patient and the catheter. The most of patients soon 
learn to hold it securely so that the air or steam passes in 



104 USE OF THE EUSTACHIAN CATHETER. 

freely. This is generally best attained by allowing the cathe- 
ter to press a little against the nasal septum, which allows the 
beak of the instrument to lie a little deeper in the lips of the 
Eustachian tube. 

Finally, we have only to say, that the catheter may be used 
as a vehicle for the introduction of solid bodies, such as metal 
sounds, or copper wires — for transmitting electricity. We 
will later on learn the special use of this. 



LECTURE XI. 



SIMPLE ACUTE AURAL CATARRH. 



Different Forms of Catarrh of the Middle Ear. — Acute Catarrh, 
its Symptoms and Consequences. — Treatment. 

Gentle^len — We come to-day to the diseases of the middle ear, 
and first to the inflammations of its mucous membrane. Ca- 
tarrh of the middle ear, may be designated as either Simple or 
Purulent, and each has an acute and chronic form. A primary 
inflammation of the bony wall of the middle ear hardly occurs, 
any more than a periostitis of the external auditory canal, of 
which we have previously spoken. The separation of the mu- 
cous from the bony covering of the middle ear, is anatomically 
impossible ; and how shall we distinguish their different affec- 
tions ? Here, still more than in the bony part of the external 
auditory canal, each intensive inflammation of the covering of 
skin must bring with it an interruption of the functions of the 
bone lying under it ; for the membrane which we are accus- 
tomed to call mucous, is at the same time the carrier of the 
vessels for the bone, it is also periosteum as well as mucous mem- 
brane. Every inflammation of the cavity of the membrana 
tympani is also an inflammation of the periosteum ; every ca- 
tarrh a periostitis. If the inflammation be chronic in its 
course, a thickening of the mucous membrane, and a hyper- 
trophy of the bone, a hyperostosis more easily occurs ; while 
in acute processes it is known that the mucous membrane in- 
clines more to ulceration, and the periosteum to atrophy of the 
bone, inflammatory softening and superficial caries. I have 
often seen diseases of the bones of the middle ear, as the result 
of very acute or long existing inflammation of its soft parts. 
I have, however, seen no cases of primary periostitis, and ac- 
cording to my views such exists only in nomenclature, and is 
to be adhered to only by a straining of facts. 



106 SIMPLE ACUTE AUEAL CATAEKH. 

Simple Acute Catarrh of the Middle Ear. — For the sake of 
brevity, and as only the middle ear is covered with mucous 
membrane, we may say, Acute Catarrh of the Ear, or Acute 
Aural Catarrh. 

I have hitherto observed these cases, mostly in the early 
spring and late fall, developing themselves after " catching 
cold," such as getting wet through, and generally in connec- 
tion with other catarrhal inflammations of the nasal passages 
or fauces. It may be said, in general, that persons inclined to 
inflammations of mucous membranes are very apt to have in- 
flammations of the middle ear. We often find the acute form 
arising in many cases, when the patients have been suffering 
for a long time from the chronic form ; the most cases which 
I have observed, have been those where the patient has suf- 
fered for a long time from deafness of one side, in consequence 
of chronic catarrh, and the hitherto healthy ear would then be 
attacked with the acute disease. People who to all appear- 
ances had heard well, certainly well enough for all their duties, 
had suddenly become limited to hearing only the loudest 
sounds. I have observed these cases especially often in men 
in middle life, often extending from a secondary syphilitic 
eruption upon the mucous membrane of the mouth. I have 
only seen seven cases, in which the aural catarrh was on but one 
side ; and on close examination, you will almost never find the 
other ear entirely free from disease. The deafness of the most 
prominently affected ear is generally of a high degree; not 
seldom a total deafness exists. The loss of hearing generally 
occurs quite suddenly, and is consequently the more marked ; 
and yet the patient will often remember that some time before 
the sudden seizure, he had noticed a slight occasional diminu- 
tion of his sharpness of hearing. With the deafness, the 
patient sometimes experiences nothing more than a feeling of 
pressure and fulness in the ear. Much more commonly, how- 
ever, there is in the first stage of the affection severe pain 
referred to the deep parts of the ear, sometimes lasting only a 
night, and occasionally some days, with intervals ; always 
exacerbating at night, and which, causing so much loss of sleep, 
pulls the patient down very rapidly. This pain is not increased 
by pulling upon the meatus auditorius externus, or by press- 
ure in the vicinity of the outer ear ; but is increased by swal- 



SIMPLE ACUTE AURAL CATARRH. 107 

lowing, or any motion of the jaw or general movement of the 
head. In one case the taking of cold water caused so much 
pain, that it was obliged to be warmed before using it. This 
pain is often accompanied by toothache, and it must be here 
stated that pain in the molar teeth is often hard to distinguish 
from pain in the middle ear. In severe cases, the pain will 
be referred to the mastoid process, and this is sensitive to 
strong pressure, when no external evidences of disease can be 
discerned. The pain generally runs over the whole side of the J 
head, being more severe in the front part, in the region of the 
frontal sinus. Noises in the ear are scarcely ever wanting, 
and they form part of the greatest trouble of the patient, on 
account of the great hammering and pounding going on there. 
One patient said it seemed to him as if an empty barrel were 
struck upon close to his head. The patients are often in doubt 
if these noises are not real ones being made near them. Add 
to all this, that the patients have an intense heaviness in the 
head, however quietly they may lie in bed, and often returning 
vertigo ; that febrile symptoms of variable degree scarcely 
ever fail, which increase in the evening almost to delirium ; 
and you will more easily understand how it is that persons 
who a few days ago were not disturbed in the least in under- 
standing all that was said, and not at all hindered in their 
daily occupation, now bear in their faces the picture of most 
intense anxiety, while with wide-opened eyes they listen for 
each word which has no sound for them ; and in what haste 
they are to know whence come these symptoms, and how they 
are made helpless by fever, pain, and loss of sleep. 

You will understand, I say, how the patients make the 
impression of delirium upon you, and you will not wonder 
that acute catarrh of the ear is sometimes called meningitis, or 
acute congestion of the brain, especially when the pain in the 
ear has been so extended as no longer to be locally distin- 
guished, when the deafness on the one side escapes notice, and 
thus the attention of the surgeon is in no respect turned to the ear. 

I can assure you that many persons have come to me with 
" nervous deafness," according to the statement of their physi- 
cians, induced by an inflammation of the brain, which an exa- 
mination of the ear showed to be a consequence of acute catarrh 
of the cavity of the tympanum. 



108 SIMPLE ACUTE AURAL CATARRH. 

It is especially hard to distinguish acute aural catarrh, in the 
case of children, from a congested condition of the brain, and it 
seems probable to me, from some anatomical facts which I will 
lay before you in the course of these lectures, that purulent 
catarrh very often occurs in children, and that its symptoms 
are very often mistaken. 

You remember the connection of the vessels of the cavity of 
the tympanum, and of the dura mater, which is made by means 
of branches of the Arteria meningea media. We can 
refer every peculiar vertigo and irritation of the brain to this 
fact. 

We should remember, however, that some of these symptoms 
may be due to consecutive hyperemia of the labyrinth, or 
partly to the pressure of the collected secretion on the mem- 
branes of the fenestras. If we examine the ear, during an 
attack of acute catarrh, we will find the external auditory 
canal wholly unaltered, if we except an increased redness of the 
membrana tympani. In trivial cases this only appears as a 
light red mingled with the grey color of the membrane, com- 
municated from the injection of the mucous membrane of the cav- 
ity of the tympanum. In this way the shining appearance of the 
drum is lessened, or may be entirely removed. It ceases to reflect 
the light evenly in some portions in consequence of its infiltra- 
tion, and thus the coniform light spot, which we are accus- 
tomed to see on the membrana tympani, on the anterior and 
lower portion, can no longer be discerned. The handle of the 
malleus, in all cases where the surface of the membrane is not 
much affected, remains plainly visible, and this is a point which 
helps us in our exclusive diagnosis ; for in such a case, the situa- 
tion of the affection must be deeper than the membrana tym- 
pani. In some cases, however, in consequence of the greater 
infiltration of the epidermis and cutis, we can no longer see the 
handle of the malleus. The vessel running over it will be seen 
filled with blood, so that we have a red line in the middle of the 
membrane, running from above downward, and the surface of 
the drum appears dull, of a bluish grey color. Sometimes 
minute vessels are seen in the periphery of the membrane, 
which is uneven, either in consequence of the increased secre- 
tion pushing it forward, or of swelling of the various parts. 

These appearances are of course dependent upon the severity 



SIMPLE ACUTE AUEAL CATARRH. 109 

of the attack, and on how long the process has gone on, before 
an examination takes place. If there has been previous inflam- 
mation and thickening of the membrana tympani, these symp- 
toms of hyperemia will not appear. In cases of long con- 
tinued chronic catarrh, and when a sub-acute attack super- 
venes, all these symptoms will be less prominent. If we exa- 
mine the ear, in later stages of the affection, the membrane does 
not appear to have lost so much of its brilliancy ; the coniform 
point of light is changed, however — generally lessened in size. 
The membrane has something of a dull lead color, and here 
and there, perhaps, a white or yellow appearance. It is abnor- 
mally concave, and there is often seen a band running over 
from the processus brevis mallei, which has something to do 
with its concavity. I have never seen any redness or swelling 
of the external parts, in the vicinity of the ear, during the 
affection ; sometimes they are somewhat tender on pressure. 
We find, however, that the throat participates in the attack, 
there being always a severe injection of the fauces. There is 
generally pain and difficulty in swallowing, stuffing of the 
nasal meatus, dryness of the mouth, and other catarrhal 
symptoms. Many patients speak of a sensation in swallowing, 
as of sounds pressing against the ear, accompanied by varia- 
tions in hearing. After the sense of heaviness in the head and 
the febrile symptoms have disappeared, the dull feeling in the 
ear and deafness remain for a long time. Crackling occurs 
oftener in the ear, and the patient always has the hope that 
some time, sooner or later, the loud report, so famous for being 
the prelude to restoration to hearing, will occur, and he will be 
well again. It is really true that we may occasionally observe 
such a case, where a patient hears a loud report in his ear, 
during sneezing or yawning, and that the hearing is greatly im- 
proved after it. In many other cases, however, in spite of 
treatment it remains for months and years the same, until at 
last the catheter is introduced. 

Prognosis. — This must be considered good, in a case of simple 
acute catarrh of the ear, where it has not gone on to perforation 
of the membrana tympani. The deafness can almost always be 
somewhat improved. There is, however, somewhat of uncertain- 
ty in the prognosis, in that relapses are of frequent occurrence, 
and still oftener an inclination to continue as chronic catarrh. 



110 SIMPLE ACUTE AUKAL CATARRH. 

We may very often see cases, in which, after an attack of acute 
catarrh, the hearing is completely restored, and is sufficient for 
all purposes, and then hardness of hearing again appears, with- 
out any other symptoms. In some cases, however, sub-acute 
symptoms accompany this gradual loss of hearing power. Many 
patients will remember an acute attack, during which they 
were entirely deaf, but recovered the hearing power by means 
of constitutional treatment, and in the course of years have 
become gradually deaf. These facts may be explained in two 
ways. In persons who have had an acute attack of catarrh, of 
any kind, there remains a tendency to the same affection. 
There are also some reasons drawn from anatomical considera- 
tions. Among the most common consequences of acute aural 
catarrh, are thickenings of the mucous membrane covering 
the cavity of the tympanum, and also the formation of various 
adhesions, which are developed from the previous contact with 
the swollen membrane, and especially the connection of the 
different parts of the middle ear, which are normally separated 
from each other. Such adhesions occur most commonly 
between the membrana tympani and promontory, between the 
membrane and the incus, or the same and the head of the 
stapes, and still more often between the two niches of the fenes- 
tra ovalis and rotunda. It is clear that when such adhesions 
have taken place, and the space of the cavity is so much 
diminished, each swelling of the mucous membrane, such as 
occurs with every cold in the head, is of importance. Each 
congestion of the membrane, however small, which could pro- 
duce no effect upon a normal cavity, will, in one that has been 
narrowed as above described, produce an effect which will 
diminish, in a sensible degree, the sharpness of hearing. Fur- . 
thermore, we may believe that these adhesions, and growing 
together of the walls, even if they do little harm to the hear- 
ing, are a source of irritation, which may be the basis for a 
congested condition. It is well known that such a condition 
of things is observed in the eye, when in consequence of adhe- 
sions between the iris and the capsule of the lens, the so-called 
posterior synechia takes place. In the accommodative process, 
and in all the movements of the iris, there becomes an irregu- 
larity of motion and^ abnormal tension. A constant state^of 
congestion follows, which gives rise to repeated attacks of innam- 



SIMPLE ACUTE AURAL CATARRH. Ill 

mation. What was once explained as resulting from a " rheuma- 
tic diathesis," now can be explained as from a pure mechanical 
cause, since the first inflammation left the damnum permanent 
behind, from which a constant influence is excited on the 
iris. 

There is a similar condition of things in the ear, even if we 
are not correct in ascribing a certain amount of accommodating 
power to the stapedius and tensor tympani muscles. Still 
their co-existence and muscular structure give evidence that 
they are the source of motion to the parts on which they act. 
These motions must certainly be irregular, and out of harmony, 
if the parts to be acted upon are confined to a certain degree 
by adhesions. We may conclude that in the ear, as well as 
in the eye, a congested condition is maintained by such a syne- 
chia, and made the ground of repeated attacks of inflammation. 
As each iritis, which leaves behind a synechia, retains a ten- 
dency to a return of the inflammation, and to formation of new 
adhesions, so we must believe that each catarrh of the cavity 
of the tympanum will more or less affect the ear injuriously 
later, and the more that adhesions have been left, behind. 

Treatment. — We shall best accomplish this, and prevent 
the above results, if the catheter be introduced as soon as pos- 
sible. According to the advice of authors I formerly delayed 
the introduction of the instrument until the acute inflamma- 
tory symptoms had disappeared, lest I should excite pain, and 
do injury to the parts. I have satisfied myself, by many expe- 
riments, that we by no means are obliged to wait so long, and 
that we shorten the inflammatory process so much the earlier 
by introducing the catheter. I have sometimes introduced 
the instrument at a time when the membrana tympani was 
greatly injected, and the patient had intense pain in the ear. 
Instead of an increase of pain from the introduction of air, 
the patient always found it lessened, if not at the very moment, 
at least in a short time after. In short, the patient began to 
improve from that time. Recall the condition of the ear dur- 
ing the inflammatory process, and you will explain this. The 
membrane is everywhere swollen, secretion increased. This 
secretion fills the cells of the mastoid process as well as the 
cavity of the tympanum, and this secretion cannot find exit, 
because the Eustachian tube, which is of the same structure, 



112 SIMPLE ACUTE AURAL CATARRH. 

is affected in the same manner, and its swollen walls prevent 
egress. If we re-open this passage by a strong blowing in of 
air, the secretion will be softened, the pressure removed from 
the walls of the cavity of the tympanum, and especially from 
the susceptible membrana tympani. It often occurs, that we 
are not willing to attempt the introduction of the catheter on 
a suffering patient from fear of the impression which what 
may seem to him a great operation may make upon him. 

You will use local blood-letting in the first stages, whether 
you are able to use the catheter or not, with a cathartic of calo- 
mel and jalap, 2-3 grains of the former, with 5-8 of the latter 
in a powder, of which 4-6 may be taken during 24 hoars, and 
4-6 leeches be applied, partly just anterior to, and partly just 
under the external meatus. The severe pain will generally cease 
with this treatment ; when it does not, the ear may be filled 
every hour with warm water, which the patient allows to 
remain in about fifteen minutes. The patient should remain 
in bed, and gentle diaphoresis be produced (with aq. acetat. 
amm. in table-spoonful doses). We must look after the catar- 
rhal symptoms of the fauces and nose, and so soon as motions 
of the throat can be borne, let the parts be gargled with an 
infusion of marsh mallow, to which a little borax is added. It is 
sometimes advised to give an emetic in these cases, especially 
tartrate of antimony and potash, or a remedy to cause sneez- 
ing, in order that by means of the severe shaking of the head, 
through the vomiting or sneezing, the mucus may find its way 
more easily through the Eustachian tube. I confess, I think 
that such a strong impression, as by severe sneezing or vomit- 
ing, may produce a somewhat dangerous effect on the mem- 
brana tympani, — since its rupture might be easily produced. 
The introduction of the catheter is certainly not accompanied 
by so much danger, and its effect is more easy to regulate. If 
the acute stages be once passed, the treatment is not different 
from that of chronic catarrh, which we will come to speak of 
in the next lecture. 



LECTURE XII. 



CHRONIC AURAL CATARRH. 



Its Course and Subjective Symptoms. — Many Peculiar " Nervous '- 
Symptoms. — Change in the Appearance and Color of the Mem- 
brana Tympani. — Thickening of the Membrane. — Calcareous 
Deposits. 

ilemen — The chronic form of catarrh of the ear is cer- 
tainly its most frequent affection, and most common cause of 
deafness. To describe it in brief, we may say that it consists of 
repeated swelling and gradual thickening of the mucous mem- 
brane of the middle ear, which proci nerally accompa- 
nied by an increased secretion, while the membrane is in a 
state of congestion. Chronic catarrh is an affection of every 
time of life, occurring often in childhood, where it is oftener 
developed from an acute or sub-acute process. In advanced 
life it is often the cause of hardness of hearing. It cannot be 
denied that there often exists a hereditary disposition to 
chronic catarrh. I am acquainted with families who are long- 
lived and in other respects healthy persons, in which there is 
no trace of struma or tuberculosis, and when the greater num- 
ber of the family, although in different circumstances in life, 
suffer from chronic catarrh, and as a consequence become 
partially deaf. The affection very often appears with persons 
of a strumous or tuberculous diathesis, and all persons who are 
apt to suffer from catarrh of any part of the mucous membrane. 
The subjective symptoms of chronic aural catarrh are often so 
trifling, that the patient is not able to designate the begin- 
ning of his complaint. The process often only makes itself 
known by its results, in a gradual and slowh r increasing deaf- 
ness, and which the patient only became aware of when it 
had reached a certain grade, sufficient to disturb him in his 
calling in life. Such cases, when the patient complains of no 



114 CHRONIC AURAL CATARRH. 

further symptom, of no pain, no noises in the ear, no abnormal 
sounds, only a persistent and slowly developing deafness, are 
very commonly considered cases of nervous deafness, and are 
only to be explained by a thorough and exact examination of 
the parts, and especially of the membrana tympani. In very 
many cases, one subjective symptom, — noises in the ear, — is 
present in connection with the slowly increasing deafness. 
The pain which occurs in chronic aural catarrh is generally 
of short duration, appearing only when the patient is exposed 
to severe cold, or the ear to a draught of wind, and is described 
as a biting, gnawing pain, and soon passes away. The patients 
also complain of a feeling as if the ear were " stopped up," of 
fulness and heaviness in it, and these symptoms appear gene- 
rally in the morning on awaking. It is a pure characteristic 
symptom of chronic catarrh, when patients complain that in 
the morning, after having slept very long, they feel an in- 
creased heaviness in the ear, and hardness of hearing. 

Many are disturbed very much from sleep, by sounds, on 
placing the head on the pillow, which do not trouble them 
when up. This described feeling of fulness and heaviness in 
the ear increases, in many patients, with the slightest causes 
which can produce a congestion of the head, or which can 
check the passage of blood from it. We find, then, that after 
drinking wine or strong tea, after bending over at work, as, for 
instance, at the writing desk or embroidery frame, or when the 
patient is, from any cause, bodily or mentally fatigued, this 
feeling of fulness and heaviness appears. The influence of 
temperature is greatly felt in these cases, so that we find that 
patients hear the best in a cold dry season ; and, on the con- 
trary, the hearing power is much diminished in cold and wet 
weather, or in very severe summer heats. Sudden changes of 
temperature always affect the patient badly. Patients com- 
plain, especially, of hearing sounds as if muffled. If they pass 
from cold air into warm, there is seldom any unpleasant sensa- 
tion, but if from warm to cold, they sometimes speak of pain 
occasioned. ^ The noises in the ear are not heard so much in 
free, fresh air, as in a closed room, especially in one that is 
overheated. A number of these subjective symptoms depend 
on the chronic, irritated condition of the nasal passages and 
fauces, the membrane of which extends to the Eustachian tube. 



CHRONIC AURAL CATARRH. 115 

There is still another class of symptoms, which are not 
uncommon in chronic catarrh. They may be explained partly 
by referring them to similar affections of the nasal passages, or 
of the frontal sinus, or to an increased pressure on the con- 
tents of the labyrinth, from long closure of the Eustachian tube, 
or an abnormal condition of the fenestra ovalis and rotunda, 
or from an irritation of the otic ganglion, or the plexus of 
the sympathetic, situated in the cavity of the tympanum. 
These symptoms are as follows : 

A continued feeling of pressure and heaviness in the head, so 
that vertigo often arises, a feeling of not being equal to any kind 
of mental exertion, each long-continued fixing of the attention 
being wearisome, and this, in people who were previously 
able to read and write for hours without any sense of weari- 
ness or oppression, but who, now, cannot continue any such 
employment but for a short time. Patients often express their 
symptoms by saying that thinking has become hard for them, 
they feel as if pressure were made upon the brain, or as if it were 
in motion. A young physician afflicted with this disease, said 
to me, " I can't seize an idea any more." In many cases, 
after long continued and severe mental labor, these symptoms 
of fulness and pressure increase to a severe pain in the head, 
which troubles the patient more than deafness and other symp- 
toms. Other patients, and also those who are not at all to any 
sensible degree disturbed in their hearing power, speak of an 
unusual irritableness, of being suddenly without reason 
overcome by very sad thoughts and forebodings, which 
sometimes increase to weeping. For a long time, 1 considered 
these last named symptoms as only accidental, and noticed 
them in my history of cases, until their frequent recurrence 
suggested to me, that they were of some importance. They 
were present, not only in sensitive females, but also in the most 
clear and strong-minded men. The connection of these affec- 
tions with the complaint was also established, in my mind, from 
the fact that after a purely local treatment they disappeared, 
and that they appeared in regular order, with a relapse of the 
affection. 

You see, gentlemen, how many symptoms we have before 
us, which are generally classed together as nervous symptoms. 
You will not be very much surprised when I tell you that 



116. CHRONIC AUKAL CATARRH. 

formerly, the greater number of cases of chronic catarrh of the 
ear, were called nervous. You will understand the confound- 
ing of the diagnosis, when you understand that the changes 
in the membrana tympani which occur in this disease are of 
the kind which you could not distinguish in the previously 
practised methods of examination. 

The objective symptoms are various and numerous, compris- 
ing not only what may be seen on the living, but also on the 
dead subject. First let us speak of the appearances, if we 
examine the living subject. The external auditory canal takes 
no part in the process ; now it is very dry, again very full of 
cerumen. We have seen in our previous study, that the 
secreting power of the canal depends rather on the general 
cutis than on any morbid processes of the deeper parts. The 
external surface of the membrana tympani has generally the 
normal lustrous appearance, not speaking of those very old or 
subacute cases where it is dull and obscured. The shining 
coniform point of light is very often changed in appearance, 
its borders not seeming distinct, very seldom it seems increased 
in size, oftener reduced to a mere point, sometimes wholly 
disappears. All these latter named conditions indicate an 
alteration of the degree of tension of the membrana tympani. 
Yessels are only seen on the membrane when a recent con- 
gested condition is present, and these run over the handle of 
the malleus or behind it. The malleus is generally seen very 
distinctly, the corium not being thickened. Sometimes it is 
pushed forward or drawn back a little, in which case the pro- 
cessus brevis mallei is the more prominent. The membrana 
tympani is often abnormally concave, which we have already 
spoken of in our remarks on the adhesive process. 

The appearance of the membrana tympani, in chronic aural 
catarrh, may be distinguished from that in the normal condi- 
tion, in that it is less translucent, and somewhat thickened. The 
natural pearl gray appearance is changed to a dark gray ; the 
color of the membrane, in the long continued course of the 
disease, passes through all the intermediate changes, from a 
whitish gray to a pearl white ; from a lead color to a yellow. 
The periphery is often the most intensely gray, it often even 
appears as a distinctly defined ring of various width. On the 
edge where the mucous membrane of the cavity of the tympa- 



CHRONIC AURAL CATARRH. 117 

nam continues itself where, in a normal condition, the mem- 
brane is most developed, the morbid thickenings are the most 
extensive. 

However, we do not always find the appearance of the 
membranatympani much changed in chronic catarrh, when the 
cases are recent, but the catheter and the other symptoms verify 
our diagnosis. It often appears a little dull in its appearance, 
and moist, in which case a little yellow color is mingled, and 
some points are less translucent. The appearances are not 
equable, either in color or density. We often find, in the 
posterior half of the membrane, a spot in the form of a whitish 
gray, opaque half moon, which lies between the outer edge of 
the membrane and the handle of the malleus, so that there is a 
portion normally translucent in each direction. Wilde has 
likened this half moon shaped opacity to an arcus senilis 
cornea. It can be seen in young persons, and is by no means 
a constant appearance. AVe find also, in the same position, 
other calcareous deposits, beginning generally in a round shaped 
spot; this in its development may unite with the posterior half 
of the half moon shaped one, and thus form a ring in the shape 
of a long drawn out horse-shoe. These calcareous deposits 
are easily distinguishable from the tissues round about, and arc 
not to be mistaken. They resemble atheromatous spots, on the 
internal coat of an artery. Sometimes they penetrate all the 
layers of the membrana tympani, sometimes they are situated 
next to the unchanged outer surface of the membrane. These 
calcareous deposits are seen in early youth, and with few excep- 
tions they occur where there is a high degree of deafness, so 
that similar processes may have occurred on the membrane of 
the fenestra ovalis and f. rotunda. Besides these changes there 
sometimes appear thickened, varied colored lines running 
from the centre to the periphery, which are first plainly seen 
after the air bath, or blowing upon the membrana tympani. 

There also appear peculiar white points on the membrana 
tympani, which undoubtedly have their situation in the 
mucous membrane, but of whose nature I can give no nearer 
idea. 



LECTUKE XIII. 

SIMPLE CHRONIC CATARKH (CONTINUED-). 

Morbid Changes in the Fenestra Ovalis and Rotunda, and their 
Effect in Diminishing the Hearing Power. — The Value of 
Auscultation of the Ear as a Means of Diagnosis. 

Gentlemen — Before we go on to a further consideration of the 
condition of the membrana tympani in chronic catarrh, and 
explain how another class of changes extend to it, I would like to 
call to your attention some anatomical considerations as to the 
cavity of the tympanum. I would especially remind you of 
the small size of the long diameter of the cavity, and how short 
the distance of the membrana tympani from the opposite wall 
of the labyrinth and the ossicula auditus. The long diameter 
of the cavity of the tympanum is from 3 to 44- Mm., mea- 
sured from the end of the handle of the malleus only 3 Mm. ; fur- 
thermore the extremity of the long process of the incus is only 
2 Mm. from the posterior and npper portion of the membrana 
tympani, while the head of the stapes is 3 Mm. Every swell- 
ing of the mucous membrane of course decreases their dis- 
tances, and it may extend so far that the mucous surfaces may 
touch each other. Adhesions may occur from such a contact 
of the two membranes, or an abnormal connection by means 
of a pseudo-membrane. The less the distance of the parts 
from each other, the easier will such adhesions occur. TTe have 
further to remember that the cavity of the tympanum is con- 
nected to the wall of the labyrinth in two ways. First, by 
means of the chain of little bones of hearing, and by means of 
the tendons of the tensors of the tympanum, which pass ob- 
liquely through the cavity, so that an abnormal connexion of 
the opposite surfaces can easily occur. 

"We have previously seen how the presence of these adhe- 
sions may be determined by examining as to the convexity or 



SIMPLE CHRONIC CATARRH. 119 

concavity of the membrana tympani during the administration 
of the air-bath through the catheter. Such adhesions are not 
only consequences of acute catarrh, but also occur in the course 
of the chronic form. 

All these changes in the membrana tympani show ns that 
its mucous surface has previously been the subject of inflam- 
matory action, and the examinations of morbid anatomy 
show us, that the membrane is affected in toto, if, perhaps, in 
different degrees of intensity. Wherein any pathological exa- 
mination of such a catarrhal process has shown us changes on 
the inner surface of the membrana tympani, we may conclude 
that the other parts of the membrane are also affected, espe- 
cially if there be any considerable deafness. A number of 
changes of structure may exist, however, without disturbing 
the patient very materially. The hearing will be certainly not 
normal, but it may be amply sufficient for the ordinary wants 
of business and social life, so that the patient may be classed 
as among those who hear well, certainly not as among those 
who hear badly. There are a number of cases of hardness of 
hearing, which are unknown to the friends and companions of 
the patient, as well as to himself. Considerable thickenings of 
the membrana tympani, when they do not co-exist with other 
changes, are never accompanied by a high grade of deafness ; 
and if such be present, we may be sure that morbid changes 
have taken place in other parts'. Now, what further changes 
do we observe on the dead body, as a result of catarrh of the 
middle ear ? It is only on the dead subject that we can learn 
the changes, other than these on the membrana tympani. The 
general thickening and solidifying of the mucous membrane 
of the middle ear is very often extended to the articulation of 
the little bones of hearing — the osslcula auditus, especially to 
the articulation of the malleus and incus, and the capsule of 
the joint becomes thicker, thus its motion is impaired and the 
articulation becomes rigid. 

The fenestra ovalis and fenestra rotunda are among the 
most important parts which participate in the effects of a chro- 
nic catarrhal process. We often find the little bony canal, 
or niche on the end of which the membrane of the fenestra 
rotunda is attached, covered over with a pseudo-membrane, or 
the mucous membrane of the niche is hypertrophied, and thus 



120 SIMPLE CHRONIC CATABRH. 

narrowed, or even entirely filled, and stopped up with thick- 
ened and vascular mucous membrane, as if closed with con- 
nective tissue. The so-called membrana tympani secondaria, 
or membrane of the fenestra rotunda, is often thickened and 
even calcified. It is clear, that when in this manner the elas- 
ticity of the membrane is impaired, or completely destroyed, 
it will be also true of the foot or base of the stapes (which 
is attached to the margin of the fenestra ovalis), since the 
fluid filling the labyrinth, and lying between the fenestra, can- 
not oscillate from the absence of elastic walls. Similar mor- 
bid changes take place also in the membrane of the fenestra 
ovalis, which is connected with the base of the stapes. Some- 
times the stapes is fixed in one direction or another by abnor- 
mal bands of adhesion. Sometimes it is wholly immovable in 
swollen mucous membrane, or covered with rigid connecting 
tissue. All these abnormal conditions of necessity interfere 
with the important function of the chain of little bones, and 
therewith with the labyrinth in its power of conducting sounds. 

The above described changes on the fenestra ovalis and 
rotunda, are of a kind of which the membrana tympani gives 
no evidence. To this class also belong the very commonly 
seen abnormal bands, which lie between the membrana tym- 
pani and the different walls of the cavity of the tympanum, 
between the tendon of the tensor tympani and the ossicula 
auditus, and which more or less fill up the air-holding spaces 
which are between the contents of the cavity. More exact 
descriptions of the changes seen on the dead subject have no 
value, for each section shows different appearances. You will 
best understand the varying nature of the changes, by observing 
the various preparations which I lay before you.* It only 
remains to be said that such adhesive processes almost involve 
the tendons of the tensors of the tympanum, and the articula- 
tion of the incus with the stapes, being so favorably situated 
for these changes. 

You see then, gentlemen, that the greater number of these 
changes can only be observed on the dead subject. VTe can 
only conjecture with some certainty as to an abnormal growth 

» See Yirchow's Archives, vol. 17, p. 1-S0. Toynbee's Catalogue of Preparations 
Illustrative of Diseases of the Ear. London, 1857. 



SIMPLE CHRONIC CATARRH. 121 

on the fenestra oralis and rotunda, when we are dealing with 
cases of deafness of high grade, and the effects of these, in 
accordance with all our present knowledge, cannot be referred 
to an abnormal condition in the labyrinth or nervous system, 
but to catarrhal processes in the cavity of the tympanum. 
The greatest acoustical importance undoubtedly belongs to 
these two fenestra'; probably they are the most important of 
the whole peripheral portion of the sound conducting system ; 
but our present stage of physiological diagnosis gives us no 
useful hypothesis, not to say certain diagnostic evidences, on 
which to base an opinion as to whether the abnormal condition 
is in the vestibule or cochlea or where. It is, however, to be 
believed that certain abnormal conditions of the middle ear 
are due to adhesive processes, which we cannot detect from 
any appearance of the membrana tympani. 

These processes have an influence upon the kind of sounds 
heard in auscultating the ear, and we may thus get an occa- 
sional indication of their presence. 

Among the sounds heard in auscultation, are peculiarly 
moist short clapping sounds, which from their nearness to the 
listener's ear, seem to be in the cavity of the tympanum, but 
which are easily to be distinguished from the formerly described 
knocking sounds. I am able, as yet, only to indicate these 
sounds, without giving you their relative importance. This 
latter can only be learned by post-mortems in cases where 
such sounds have been accurately noted before death, or possi- 
blv bv auscultation on the cadaver. Even if in the greater 
number of cases, we are able to determine the existence of 
chronic catarrh, still a more exact examination of the patient 
by means of the air bath through the catheter, should always 
be had. We should see further on, in our meeting, what value 
this more close examination has for the prognosis. In this 
way we decide how much part the Eustachian canal takes in 
the process ; if its mucous membrane be swollen or puffed out ; 
if there be any abnormal mucous secretion in the tube or 
cavity of the tympanum. Very often it occurs that abnormal 
conditions of the membrana tympani first announce themselves 
after the air bath — for example the radiated adhesions, and the 
observations of the membrane during the passage of air into 
the cavity of the tympanum, as to its elasticity and mobility, 



122 SIMPLE CHRONIC CATARRH. 

which can be determined in no other way. However, if we 
do consider the condition of the Eustachian tube as important 
for diagnosis in chronic catarrh, we must be careful lest we 
overestimate it, and draw conclusions which cannot properly 
be deduced. If the stream of air passes clearly and fully into 
the cavity of the tympanum, with no mingling of rattling, 
gurgling sounds, it proves nothing more than that at the 
moment of examination there is no abnormal swelling of the 
membrane or morbid increase of secretion. It certainly 
does not prove that such a condition did not precede the 
present, and that the hardness of hearing does not depend on 
changes in the middle ear — that is, on a catarrhal process. 
In many cases, the appearance of the membrana tympani, the 
history of the patient, in short all the other symptoms indicate 
for the cause of the ear affection a chronic catarrh of the 
middle ear, a thickening of the membrane, and yet the air 
passes through the canal without any hindrance or any 
sound indicating increase of secretion. Yes, we find in some 
extremely chronic cases of catarrh the stream of air passes 
into the ear with an extremely full tone, and this may be well 
observed when the patient is fully deaf in one ear, while in the 
other the inflammatory process is just developing itself. 'In 
the first ear, the sounds are full and free, while in the other, 
the later affected and better ear, there is considerable obstruc- 
tion, and the air enters only with a thin whistling sound, or 
during swallowing. Yery often, after a long continued inflam- 
mation, there appears a dryness of the external surface, and a 
shrinking of the connecting tissue, as, for instance, after intense 
trachoma, there is an abnormal dryness of conjunctiva, and a 
complete want of secretion (xerophthalmos). These tacts 
observed on the living, will tell what should be seen on the 
cadaver. 

I have often called your attention in my cited sections, to a 
remarkable width of the ear trumpet, in its upper section, and 
this was in cases where for a long time a great amount of 
purulent secretion had taken place in the cavity of the 
tympanum* Here we may believe that a stretching of the 
walls had occurred, by means of the massing of the secretion, 

* Yirchow's Archiv, voL 18, sec. 4. The same, Vol. 21, p. 299 and 303. 



SIMPLE CHRONIC CATARRH. 123 

or that they were cases of old catarrh of the ear, which left 
behind morbid changes in the cavity of the tympanum.* 

Catarrhal inflammations also occur, which are localized in the 
middle ear, and produce little or no change in the Eustachian 
tube. Finally, many of these processes are interstitial thicken- 
ing of the tissue itself, and showing itself very little, in increase 
of secretion and exudation. In very many cases, every 
anomalous symptom from the Eustachian canal may be wanting 
on auscultation, and yet the hardness of hearing be due to a 
pathological condition of the mucous membrane of the cavity 
of the tympanum, to a chronic catarrhal inflammation. I 
dwell on this point, because so many practitioners have believed 
that they should only make the diagnosis u aural catarrh," 
when there are murmurs, and rattling sounds in the use of 
the catheter, and when the permeability of the Eustachian 
trumpet is removed or interfered with, for this reason " catarrh 
of the tube," is said, instead of "catarrh of the middle ear." 
This over estimated importance of the tube, and of its condi- 
tion, as ascertained by auscultation, goes hand in hand with a 
too slight observation of the changes in the cavity of the 
tympanum. 

Morbid anatomy, however, and an exact examination of the 
membrana tympani, reveals the frequency of this affection. 
The above named nomenclature is not confined to general 
practitioners and specialists of former times; but it maybe 
found, also, in the writings of many late aural Burgeons. You 
will understand, then, gentlemen, that in this manner, which I 
have just detailed to yon, a great deal of catarrhal inflamma- 
tion, especially the so frequent interstitial thickening processes 
of the mucous mnibrane of the cavity of the tympanum, are 
overlooked. 

We will see later on,, how these cases have been classified 
as cases of " Nervous Deafness," and how, by this means, 
nervous affections of the ear have won an undeserved promi- 
nence in diagnosis. 

* Yirchow's Archiv, B. xvi., sec. vii. xxL 



LECTUKE XIV. 

CHRONIC CATARRH OF THE PHARYNX AS ACCOMPANYING CHRONIC 
AURAL CATARRH. 

« 

The Connection between the Ear and the Pharynx. — Anatomical 
and Physiological Mode evident by Experiment. — Importance of 
the Muscles of the Eustachian Tube. — Examination of Cavity 
of the Mouth. — Rhinoscopy. — A Case of Exudation from the 
Pharynx.— Symptoms of Chronic Pharyngeal Catarrh. — Nerve 
Supply of the Pharynx. 

Gentlemen — You should never omit, in any ear case, to 
examine the mucous membrane of the nose and mouth. You 
will find these parts very often affected in chronic aural 
catarrh. Yery often the affection of the ear proceeds from 
a morbid condition of the naso-pharyngeal cavity being ex- 
tended from this. Many aural surgeons, almost the greater 
number of the late writers, deny, almost entirely, this connec- 
tion between aural and pharyngeal catarrh. I confess, for 
myself, that I consider it entirely unintelligible, how this con- 
nection can be held in question, when a considerable number 
of intelligent and unprejudiced patients, without being asked, 
speak of the dependence of the one inflammatory process upon 
the other, and when also the anatomical facts, physiological 
laws, and the results of treatment, confirm this view. 

Its development, as well as its structure, proves that the 
mucous membrane of the Eustachian tube is a continuation 
of that of the pharynx. In its beginning it has exactly the 
same anatomical characteristics, is thick, puffed out, and has 
a number of mucous glands, whose entrance we can gene- 
rally very plainly see with the naked eye. That part of the 
mucous membrane of the tube which imperceptibly, and with- 
out any distinctive borders, merges itself into that of the 
pharynx, is generally in the same condition with the latter, 



CHRONIC CATARRH OF THE PHARYNX. 125 

and participates in all its congestive and inflammatory condi- 
tion. Any kind of a noticeable affection of the mucous mem- 
brane in the lower section of the tube must, necessarily, in a 
purely mechanical way, extend with its effects to the higher 
lying parts of the ear. The contraction of the tube thus 
caused, a tube which is normally very narrow, and which 
very readily, especially in the upper portion, entirely closes, 
will at once shut up the secretion of the cavity of the tympa- 
num, since it cannot be removed as before. Besides, the com- 
munication thus cut off between the cavity of the tympanum 
and the pharynx, and the absorption of the air left in it at the 
time of the closure, which absorption gradually takes place, 
will render the pressure on the membrana tympani only that 
from the external meatus, and thus this membrane, as well as 
the whole chain of the ossicula auditus, is dragged abnormally 
inwards. 

If, then, the catarrh of the pharyngeal end of the tube 
always impairs the normal condition of the upper, even if it 
take no part in the inflammatory process, it is also true that 
pathological conditions continue themselves on, and we often 
find a catarrh of the middle ear, at the same time with that 
of the pharynx. This is proved by examinations on the dead 
body. On recent subjects, we often find the whole mucous 
membrane of the middle ear, at the same time with that of 
the pharynx, in a state of congestive swelling — hyperemia and 
hypersecretion. The appearances of the different parts will 
vary in accordance with the different structure. The part 
most similar to the pharynx, in the structure of its membrane, 
is the cartilaginous portion or wall of the tube which is in the 
vicinity. The covering of the tube, which in the bony portion 
is thin, pale, and without glands, becomes for a little distance 
much thicker and more full of vessels, and has also some quite 
large-sized grape-shaped mucous glands. The symptoms of 
swelling and hyperemia are naturally not so evident in the 
remaining portion of the Eustachian tube, and in the cavity of 
the tympanum itself, but they can, however, even here be 
plainly seen in the most of cases. 

Daily observation, and experience in practice, show us how 
all the mucous membranes belong to one system, and that they 
are almost always in a similar normal and morbid condition. 



126 CHRONIC CATARRH OF THE PHARYNX. 

Johannes Miiller says : The mucous membranes, in accord- 
ance with their course, have a great tendency to communi- 
cate their affections.* We see how often affections of the 
mucous membrane continue themselves " per continuation." 
Catarrhal inflammation of the conjunctiva and lachrymal sac 
occur from a cold in the head, and the inflammation of the 
buccal cavity, in typhus fever, extends itself through Whar- 
ton's duct to the little glandular canal of the parotid ; and 
it is well known how constitutional diseases — I will only name 
typhus fever, tuberculosis, and the acute exanthemata, extend 
themselves to the ear. 

Thickening of the soft palate works in a purely mechanical 
way, its size being often increased in chronic pharyngeal catarrh, 
and thus it presses on the pharyngeal entrance of the canal, 
and tends to press together the lips at the mouth of the Eusta- 
chian tube. Enlarged tonsils have also the same effect in an 
indirect way (never in a direct one), by pushing up the poste- 
rior arch of the palate and the soft palate. While we are 
speaking of the connection between pharyngeal and aural 
affections, we must remember, finally, that the muscles which 
move the palate, and assist in swallowing, are also muscles 
of the Eustachian tube.f 

The constant equalization of air between the cavity of the 
tympanum and the pharynx, is kept up by means of these 
muscles, especially during the act of swallowing, since they 
are inserted on the cartilaginous wall of the tube, and affect 
by their motions the size and shape of the opening. We do 
not know the mechanism of these muscles any more in detail, 
but that they do exert an influence on the canal is certain ; and 
we can convince ourselves that such is the case by closing the 
nose and mouth and swallowing. You will not only then hear 
an audible sound, but also feel a peculiar fulness in the ear. 
Thus much is certain : viz. that an abnormal or hindered power 
of these muscles has an influence upon their mechanism, or 
effect, and does not allow of a continued normal condition 
of the parts of the middle ear. 

It would be thought that the muscular fibres, which run so 

* Hand-Buch der Physiologie. 1844. Vol. 1, p. 651. 

f Petro-Salpingo-Staphylinus, or Elevator Palati, and the Spheno-Salpingo-Staphy 
linus, or Tensor Palati. 



CHRONIC CATARRH OF THE PHARYNX. 127 

near to the surface of the mucous membrane, and which wrap 
themselves about the glands of the soft palate, would be them- 
selves affected, in a long continued and intense inflammation, 
and underlie the changes in structure. Although this belief 
has a certain probability in it, nothing at all can be said with 
absolute certainty, since the parts have not been examined as 
to this view. A\ r e are obliged then to believe that the patholo- 
gical changes in the structure of the muscles of the palate, 
and of the Eustachian tube, have resulted from catarrh of the 
pharynx. We are able to say with certainty that their func- 
tions are disturbed by such a morbid process. 

Hypertrophy of the glands of the palate, swelling and thick- 
ening of the membrane of the pharynx and Eustachian tube, 
the most common and sometimes astoundingly excessive con- 
sequences of'catarrh, certainly increase the task of the muscles 
in question. Even if the muscles do not increase in size to 
any extent, as we see is done in the compensatory hypertro- 
phy of the heart, in valvular insufficiency, although from all 
the facts of the case we have reason to believe the contrary, 
at least a misproportion between the power possessed and work 
demanded, will be developed. The muscles of the palate and 
of the Eustachian tube will not fully perforin their duties, will 
become relatively insufficient., Now then, a normal power of 
motion of this important apparatus is positively necessary to 
secure a healthy condition of the middle ear; therefore this 
insufficiency, which is often caused by a chronic catarrh of 
the middle ear, will prevent a normal condition of the middle 
ear. 

The great importance of the palatine muscles for the hearing, 
was first made known by Dieffenbach in his showing that most 
of the patients with cleft palate were also hard of hearing. 
In these cases the muscles want a fixation point for their influ- 
ence upon the Eustachian tube, and consequently it, with the 
entire middle ear, becomes affected. According to Dieffen- 
bach, the hardness of hearing disappeared, after the closure of 
the fissure by sutures. 

You see, gentlemen, that when we examine the matter more 
closely, we find a great number of influences and ways, by 
which affections of the Naso-pharyngeal cavity can continue 
themselves on the Eustachian tube and cavity of the tympa- 



128 CHROMIC CATARRH OF THE PHARYNX. 

num. Examine, then, in every case of affection of the ear, the 
mucous membrane of the pharynx, and see in what condition 
it is. Most persons are not able, when they open the mouth, to 
hold the tongue down, so that we are compelled to use a tongue 
depressor. The best to be used are broad and short ones, with 
a hinge joint, so that one can be used as a handle. Cause the 
patient to take a deep inspiration, or to articulate a loud " a," 
the palate muscles will be elevated, and we will be able to see 
both arches of the palate, the tonsils, and the whole lower por- 
tion of the posterior wall of the pharynx. If we are able to 
press down the -whole of the tongue, instead of merely its tip, 
we can get a deeper view, including the base of the tonsils, and 
the surroundings, even to the epiglottis, whose upper portion 
in this manner, in some men, and especially in children, is 
brought to light. We will see a great many different appear- 
ances in such an examination, for there exists a great variety of 
morbid changes, which take place in these parts. Sometimes 
the mucous membrane is intensely reddened and swollen, in 
such a manner that the isthmus faucium becomes extremely 
narrowed, and the boundaries and borders of the different 
parts merged together. Sometimes only single parts are 
affected, as for instance the Uvula, which hangs down as a long 
and broad sac, or the tonsils are* very irregular and fissured 
in appearance, or the result of many previous abscesses, or 
they project out with white or yellow points of pus, reaching 
up to the centre of the soft palate. In adults of more than 
thirty years, considerable hypertrophy of the tonsils is not so 
common as general oedema of the mucous membrane ; some- 
times there appears, on a slightly red base, a few round eleva- 
tions, somewhat even and dry, like granulations, as in trachoma, 
in the stage of diffuse inflammation or in blennorrhoea of the con- 
junctiva. The mucous membrane lying between has even some- 
times a strikingly pale and flabby appearance, and sometimes, on 
the contrary, appears dense and tense, as if shrinking had occur- 
red. Large patches of oedema show themselves symmetrically on 
both sides of the pharynx, behind the palatopharyngeal arch. 
In other cases, the mucous membrane, as far as we can follow 
it, appears strikingly pale, shining and thin, only traversed by 
single varicose veins, and the thin, long, and flabby uvula 
hangs down like a needle. Irregularity in the arch of the soft 



CHRONIC CATARRH OF THE PHARYNX. 129 

palate, is less common in acute than in chronic affections of 
the pharynx ; however, we often see the uvula pushed more 
or less obliquely to one side, without any paralysis of the 
facialis. 

Yery often the space between the two arches of the palate 
is very large, without being filled up with a tonsil, and the 
posterior wall of the pharynx is much nearer ; so that the 
entrance into the naso-pharyngeal cavity is much narrowed. 

The latter named appearance seems to indicate a thickening 
of the soft palate, that is, of the broad part bordering on the 
fauces. We can assure ourselves of an irregular tumor like 
alteration in the arch of the soft palate, by means of a catheter 
introduced through the nose, and moved about in this region, 
which will give, by means of a peculiar doughy feel, the idea 
of a diffuse oedema of the upper pharyngeal space. We may 
often draw out, by means of the catheter, great masses of half- 
dry green mucus, such as are often visible on opening the 
mouth, lying in drops on the posterior pharyngeal wall, or 
firmly in crusted there. 

Until recently, we have been unable to examine the upper 
pharyngeal, or nasal pharyngeal cavity, in which the so import- 
ant pharyngeal opening of the Eustachian tube lies, except in 
those rare instances in which there was a fissure of the palate, 
or a considerable defect in the structure of the nasal meatus.* 
J. Csermaky to whose talent and zeal we are indebted for 
making practical the examination of the larynx with the 
laryngoscope, and causing it to be a developed branch of 
science, promulgated the simple as well as the good idea of 
placing the mirror in an upward direction, and thus obtain a 
view of the nasal cavity. This method of examination has 
been called Rhinoscopy, or, in later times, Pharyngoscopy. 
We use also the little mirrors as in laryngoscopy, and we gene- 
rally have only another inclination to give the handle in order 
to their use. We need, also, a tongue spatula, for which the 
jointed one, already mentioned, is the best — the patient being 
able to hold it himself ; then we may also need, in some cases, a 
broad hook for lifting up the uvula. When we have no sunlight 
for illuminating the part, which is best adapted for the purpose, 

* Gazette Med. de Paris. 1857. Number 19. 

9 



130 CHRONIC CATARRH OF THE PHARYNX. 

I use an Argand's study-lamp, over which is an illuminating 
lantern (Levin's), by means of which the light is retained, and 
transmitted through a strong convex lens. "We can either 
allow the light to fall directly on the pharynx, or turn it upon 
it by means of Semeleder's illuminating spectacles. This 
consists of a strong spectacle frame, on which, by means of a 
joint, a concave lens is fastened. In spite of all these appli- 
ances, rhinoscopy is yet by no means an easy matter ; and to be 
able to see what is to be seen, only comes after long practice. 
The parts to be seen are posterior surface of the palate, nasal 
openings, with the ends of the inferior and middle nasal muscles, 
pharyngeal opening of the Eustachian trumpet and its vicinity, 
the portion corresponding to the base of the skull, and finally 
the posterior pharyngeal wall. 

There is a great sensitiveness of the pharynx, so that its 
muscles contract spasmodically at every touch, or a tendency to 
vomiting occurs, with great constriction of the entrance to the 
throat, all of which are hindrances which not only render the 
examination difficult, but sometimes even prevent a thorough 
examination. This state of things is quite often present in 
just the patients who have affections of the ear. However, as 
the surgeon becomes more skilful through practice, these cases 
become more rare. 

The upper pharyngeal space is rarely examined with any 
exact anatomical view ; therefore, its normal as well as patho- 
logical condition is generally not well enough studied and 
understood. It is a part so hidden and off the way, that in 
ordinary post mortem sections it is rarely brought into view. 

(On page 393 of the second volume of the American 
Medical Times, will be found an interesting communication 
from Dr. J. Simrock, of this city, with an engraving of a modi- 
fied pharyngoscope. 

Dr. Simrock is one of the few gentlemen in New York, who 
practise pharyngoscopy ; and I think he would confer a great 
benefit on the profession by making known the results of his 
observations. 

You should prepare for yourselves sections of the head, or 
take from fresh subjects the two temporal bones, or its petrous 
portions, by means of two saw-cuts, one passing through the 
mastoid process, the other through the zygomatic process of 



CHRONIC CATARRH OF THE PHARYNX. 131 

the malar bone, and you will be at once surprised at the 
uncommon richness of the parts in vessels, at the succulence 
and thickness of a mucous membrane, which many physicians 
have never seen in their whole lives. You will be surprised, 
when examining this part, to find it the origin of many of the 
diseases of your patients. You will not examine many heads 
without finding some abnormal appearances in the parts. The 
most common appearance is hypertrophy of the glands, espe- 
cially in the palatine arch, where it may be so great that this 
is three or four times its usual thickness ; then, also, swelling 
and hyperemia of the whole mucous membrane, which last 
may lead to greater or smaller extravasations under the epithe- 
lium, or on the surface itself. Bloody sputa no doubt comes 
much more commonly from the upper cavity of the pharynx 
than is generally believed. How often hemorrhages occur 
under the membrane of the pharynx and in the glands, the fresh 
evidences of blood show, as well as its remains, the black 
pigment, which is so often found in the vicinity of the Eusta- 
chian tube, and mingled with the pharynx sputa. In order 
to convince one's self of the degree of development of the 
grape-shaped mucous glands of the wall of the pharynx, we 
have only to prepare a piece of its membrane and hold it up 
to the window and look through it. The peculiar protuberant 
bodies on the nasal openings are very often, also, hypertro- 
phied. In chronic pharyngeal catarrh, the trumpet-shaped 
mouth of the canal is sometimes strikingly wide, its lips stand- 
ing unusually wide from each other. AVe are able to press 
white, glairy mucus from the glands, and we sometimes thus 
uncover white and brown calcareous concretions of various 
sizes, and sac-shaped, which are firmly buried in the tissue. 

Superficial round loss of substance is seen more often than 
deeper ulcerations, such as obtain in syphilis and tuberculosis, 
exactly in the vicinity of the mouth of the Eustachian tube. 

We find folds or pockets and bands of tissue into which the 
catheter may easily pass in the fossa just behind the mouth 
of the tube (Rosen muller's fossa). Just here, where, according 
to Xolliker, great masses of mucous glands are congregated, 
being similar to the structure of the tonsils, and which are 
generally enlarged in old persons, and filled with masses simi- 
lar to pus, I found in an ear patient, who had suffered nine- 



132 CHRONIC CATARRH OF THE PHARYNX. 

teen years from asthma, a somewhat prominent swelling about 
the size of a cherry, which, on being incised, showed contents of 
a whitish yellow appearance.* In a post-mortem section of a per- 
son who had been deaf and dumb, thirty-five years old, I found 
at the same point a similar but far larger swelling filled with 
a thick, yellow, brownish mass, which consisted of mucus and 
crystals of cholesterine. Xear the swelling, and extending to 
it, were several little cysts, filled with glairy mucus. Such 
cystoid structures are, perhaps, degenerated mucous glands, 
and are often found in the throat. At least, I have already 
often observed that a patient, immediately after the use of the 
catheter, ejected such masses of puriform or mucous secretion, 
so that the patient would himself describe it as a " sac full of 
mucus," which had been pushed into by the catheter. 

In one case the ejection of such sputa alarmed me for a time 
not a little, since in its outward appearance, as well as the 
mingling of blood and mucus in the interior, it looked like 
pneumonic sputa. The patient — an old gentleman — expecto- 
rated a great quantity, in the afternoon and morning, after the 
catheter was used. When he showed me two handkerchiefs 
full of it, my first thought was of pneumonia. The patient 
relieved me of my fears, by breaking out in the voice of a 
Stentor : " You think there is something the matter with my 
lungs. In the year 1848, 1 was first president of the House of 
Commons, then my chest proved its capabilities, and to-day, I 
went again on the tribune, to cry down the noise.*' At that 
time we had the good fortune to have here the first authority 
in sputa, Biermer, so I sent the patient to him, in order that 
he might examine the sputa. At first it seemed to Biermer 
that it was pneumonic, but he found the chest perfectly sound ; 
and after a thorough examination, he decided that the sputa, 
which had alarmed me so much, must have come from the 
nose or fauces. Probably it came from some kind of a cyst, 
or mucous gland in the pharynx, which emptied its contents 
after the use of the catheter. I do not know that a similar 
case has been previously observed. 

According to Semeleder,f pharyngeal polypi appear to 
grow very often from the base of the skull. 

* Yirchow's Archives, volume 18. page 78. 

f Zeitsckrift der Wiener Aerzte. 1S60. Number 47. 



CHRONIC CATARRH OF THE PHARYNX. 133 

Rhinoscopy will enable us to detect the above-named and 
other morbid appearances during life. As new and unem- 
ployed as this method of examination is, it has already furnish- 
ed us with many interesting details of the pathology of the 
naso-pharyngeal cavity, and will certainly yet win a great 
importance for the morbid anatomy of the pharynx as well as 
of the ear. 

The symptoms of chronic catarrh of the pharynx are very 
different in different cases. Often, even in the most intense 
form, the patient has no idea that he has any affection of the 
throat. He will, however, just remember, on close questioning, 
that for years, especially in the morning, he has expectorated 
considerable quantities of mucus. Others speak of a certain 
dryness or an unpleasant tickling in the throat, which is very 
annoying and demands the frequent use of cold fluids, or moist- 
ening with bon-bons, or the like. Others complain of a 
certain difficulty of swallowing, after even the slightest cold, 
and of variously severe pains accompanying it. With these 
complaints, you will also hear of a great annoyance from the 
constant accumulation of mucus, requiring some consider- 
able trouble to remove it from the throat ; and the muscles, 
thus frequently called into service, may be at length forced 
into morbid action, and vomiting be produced. This unplea- 
sant s} T mptom occurs generally in the morning just after getting 
up. As a consequence of the head being on a vertical line with 
the body during 6leep, and the long inaction of the muscles of 
the throat, a considerable quantity of mucus is collected ; this 
becomes dry and dense, and adheres quite firmly to the mem- 
brane. Thus is explained how all the symptoms of catarrh of 
the phaiynx are most common in the morning, and are the 
more prominent the longer the patient has slept, the worse the 
air which he has breathed during the night, and the more he 
has exposed himself on the evening before — that is, smoked 
and drank. Besides the dryness of the mouth, which is occa- 
sioned in such patients by the " cold in the head," and the 
necessity of sleeping with the mouth opened, which is caused 
by nasal catarrh, the patients feel also a heaviness in the head 
and fullness in the ears. These symptoms will be relieved 
when they have gargled the mouth, and taken a glass of 
water or cup of coffee, after which the mucus is loosened 



134 CHRONIC CATARRH OF THE PHARYNX. 

and easily removed. In some patients, however, the increased 
ejection of sputa continues during the whole forenoon. A 
patient of this class, who seemed to be a person of temperate 
habits, assured me that these unpleasant symptoms disappeared 
when he held a small quantity of brandy in his throat for a 
short time, which, he said, " cleared his wind-pipe." 

We meet with gastric symptoms quite often in connection 
with chronic catarrh of the pharynx ; symptoms which 
somewhat resemble those of a mild chronic catarrh of the 
stomach, and which must result from the connection of the 
mucous membrane of the pharynx with that of the stomach. 
The secretion of the pharynx is sometimes so excessive, as to be 
almost a pharyngeal blennorrhcea, and the whole of the mucus 
cannot be ejected ; and perhaps it may pass down into the 
oesophagus. Although we know very little of the chemical 
constitution of the sputa of the pharynx, yet we may believe 
that the stomach will not tolerate it in any great quantity. 
Furthermore, many observations have convinced me that 
many forms of the so common neuralgia which occur in 
chronic catarrh, and which generally appears as pains in the 
forehead and back of the head, are closely connected with this 
affection. In order to convince you of the possibility of such 
being the case, I have only to call to your mind the many 
headaches which depend on affections of far-removed organs. 
How very often pain in the head is one of the symptoms 
of diseases of the eye, stomach, kidneys, and very often 
of the uterus ; and we are only able to cure the disease by 
reaching the cause. Then, the palate and pharynx are parts 
very rich in nervous supply, and many nerve branches take 
part in the supply of these parts. 

Thus, the trigeminus furnishes motory as well as sensory 
fibres ; the motory from the pterygoideus internes, of the third 
branch, and the sensory as well from the second as the third 
branch. Further, the spheno-palatine ganglion communicates 
with pharyngeal branches, and with the palatini descenden- 
tes, and the otic ganglion with branches ad tensorem palati 
mollis. Furthermore, we should mention the facialis which, 
according to the most of authors, furnishes a small branch 
to the soft palate ; the glosso-pharyngeus from which, as is well 
known, a great part of the motory as well as sensory power 



CHRONIC CATARRH OF THE PHARYNX. 135 

of the throat and palate is obtained ; then the pneumogastric, 
which gives two branches to the mucous membrane and mus- 
cles of the pharynx. 

As the branches of the pneumogastric and the glosso- 
phaiyngeus have a reflex action on the pharynx, so also 
a plexus pharyngeus is formed from the sympathetic. 

Few parts of the human organism have such a rich nervous 
supply and free connection. 

Now, then, is it probable or not, that parts thus connected 
to other organs, when morbidly affected, only make it known 
by local symptoms, or should we not conclude a priori, that 
these same morbid affections must affect other near channels 
and other organs ? If we will but once examine the affections 
of the pharynx more closely, instead of thinking them worthy 
of no attention, we shall discover facts which have an import- 
ance for the whole organism, and whose effects on the various 
parts are more considerable than those I have indicated. 

It remains still to be said, that the affections of the upper 
and lower portions of the pharynx often produce a bad odor 
from the mouth and nose. Sometimes we perceive this at a 
considerable distance, so soon as the patient breathes with his 
mouth open ; more commonly we perceive it first, when making 
an examination. It has something of the odor of stinking 
cheese, and is generally unspeakably sickening and uncom- 
fortable for the surgeon, if he is at all sensitive to odors. 



LECTURE XV. 

SIMPLE CHRONIC AURAL CATARRH (CONTINUED). 

Chronic, Nasal Catarrh. — Participation therein of the Mastoid 
Cells, and the Eustachian Tube. — Prog?iosis of the various 
forms of Catarrhal Inflammation. 

Gentlemen — ¥e have now a few words to say of the chronic 
catarrh of the mucous membrane of the nose, which is very 
often connected with that of the ear and the pharynx. 

The foetid odor of catarrh, spoken of in our last lecture, 
may be a characteristic, not only of Ozoena, but also of other 
affections. We may find it in females during the menstrual 
period. The patients themselves do not appear to be gene- 
rally aware of the odor. 

The secretion is seldom increased in nasal catarrh, of which 
we are now about to speak, but generally decreased. The 
patients find themselves with their head "stopped," or "stuffed 
up ;" the nose is very dry, not requiring the use of a handker- 
chief ; they complain of a feeling of stoppage and thickness 
in the nose, and the air passes less readily through it, on 
account of^the thickness of the mucous membrane. If the 
secretion has been for a long time very abundant, we must 
examine as to polypous growths, which are sometimes found 
on careful examination, when the patient and physician have 
had no idea of their existence. ^sTasal polypi are very often 
overlooked, when they are not so large as to be pushed 
against the external meatus by a strong expiration, or when 
the permeability of the affected side is not fully impaired. It 
is possible that such have their origin in the antrum Highmorii. 
Luschka and Giraldes* have, at least, proved that cysts and 
peculiar polypoid mucous growths appear on this part. Luschka 
found in sixty sections five soft polypi in the antrum. 

* YirehcVs Archives. Volumes 8 and & 



SIMPLE CHRONIC AURAL CATARRH. 137 

We are sometimes, also, able to recognize inflammatory 
affections of the antrum on the living subject ; such patients 
speak of indescribable feelings of heaviness, and pressure 
in the molar region, which often increases to painful irritation 
and toothache ; as you know, the superior dental nerves run 
immediately under the antrum, so that they are easily subject 
to swelling on any pressure of this part. We often see yellow 
masses of mucus collected in such cases, and I am inclined to 
think that they have their origin in this neighboring cavity 
to the nose. We can introduce an ear-speculum, for the 
examination of the nasal cavity, and illuminate it by means 
of the concave mirror. The valvular speculum may be used 
with advantage, the nasal cavity having flexible walls. The 
anterior portion of the alae of the nose is often 60 enormously 
thickened, that it may be mistaken for a polypus growth. 

We remarked, in the beginning of our observations on the 
subject of chronic aural catarrh, that it consisted in repeated 
swelling and gradual thickening of the mucous membrane 
of the middle ear, which process was generally accompanied 
by severe congestion, and increased sensation on this surface. 
While I spoke of the subjective and objective symptoms, 
through which this state of things might be recognized, we 
have not attempted to separate the different parts of the ear, 
in the effects made upon them by the disease. We have now 
to consider how far we can localize these effects ; what part 
do the mastoid process and Eustachian tube take in these affec- 
tions ; of what importance are the morbid changes taking 
place in them ? 

The number and extent of the air-cells, the opposite condi- 
tions of density and porosity, are so various in the mastoid 
process, that in persons of the same age, sometimes one, 
sometimes the other, is more prominent ; and with our pre- 
sent knowledge, we are not always in a condition, in a given 
case, to say if the appearances in the mastoid process should 
be characterized as morbid or physiological. In some cases 
of thickening of the mucous membrane of the cavity of the 
tympanum of one ear, I found the mastoid process of the 
same side, with strikingly small cells, more solid in structure, 
while on the other the air-cells were very large. It cannot, 
certainly, be decided, if such a kind of difference in cell 



138 SIMPLE CHRONIC AURAL CATARRH. 

development proceeds from chronic aural catarrh. However, 
there is a very great probability, when the middle ear has 
been for a very long time in a condition of congestion and 
hyperemia, that the space-holding air gradually begins to en- 
large by means of increased secretive power, and also, through 
increased formation of bone, a hyperostotic power, which 
is often seen in all parts of the body, ends in chronic inflamma- 
tion of the periosteum. How far such an increase in density 
of the mastoid process affects the other parts, and how much 
it injures the hearing, we do not know, since no observations 
have been made on this subject; and moreover, we have no 
facts as to the greater or lesser capability of the mastoid 
cells for containing air during life. It is probable, that we 
may obtain some light by auscultation of the ear, and percus- 
sion of the bone, and by ascertaining the degree of hearing- 
power, by placing the watch over the mastoid process, 
as compared with other results. It is, however, as yet 
advisable to simply consider all these observations without 
being in haste to draw conclusions from them. Let us turn 
to the consideration of the physiological importance of the 
mastoid process, in order to determine what results must 
obtain from the described altered condition of the air-contain- 
ing power of these cells. It is a generally accepted opinion, 
that the purpose of these air-cells — this porous structure — is 
to give to this firm covering, or guard to the ear, a certain 
lightness. But there must be some further purpose than 
this. 

The air-cells of the mastoid process increase the quantity 
of air which is set in motion by means of the acoustic vibra- 
tions ; they are, with every circumscribed fixed body, and 
every circumscribed quantity of air in the vicinity of the 
labyrinth, to be compared to a resonator, or sounding-board. 
"We cannot say how far any diminution in size of these parts 
places the hearing below normal. It is possible that each 
transient deadening, each hollowness of the patient's own 
voice, which is often complained of during a catarrhal condi- 
tion, is a symptom of diminished resonance, through a filling 
of these cells with secretion. 

This hollow space in the vicinity of the cavity of the 
tympanum, has also a greater importance, in that it is a sort 



SIMPLE CHRONIC AURAL CATARRH. 139 

of air reservoir, by means of which all sudden changes in 
the cavity of the tympanum, as to the quantity of the air, 
may be equalized, and thus rendered less effective. We saw 
previously how in simple swallowing, with the mouth and 
nose closed, that the air was considerably rarefied, and the 
membrana tympani pressed inward, as we can determine 
by examination with Politzer's air-measurer. This same 
state of things occurs also in a strong respiratory action, 
as, for instance, in sneezing, spasmodic coughing, or violent 
blowing of the nose. 

We know, to reverse the case, how a strong condensing 
of the air, in the middle ear, with pushing out of the mem- 
brana tympani, can be noticed, as for instance, when air 
is pressed from the lungs into the ear. 

Again, if a sudden increase in the pressure of the air 
occurs, as for instance, from a very loud report, such as 
cannon, or trumpet, sound takes place near the ear. Think, 
gentlemen, what an effect would be produced from such a 
change in the pressure of the air upon the small quanti- 
ties in the cavity of the tympanum, and in the other parts 
of the middle ear; how easily must a solution of continuity 
occur. Either a laceration of the membrana tympani, of the 
membrane of the fenestra rotunda, a pushing of the stapes 
into the vestibule, or a separation of the extremely delicate 
articulation between the incus and stapes, or any other, 
according to the kind, force, and structure of the powerful 
movement of the air. All these accidents will be less likely 
to happen, when the pressure of the air is more equally 
divided by having access to the various spaces. 

"When the membrana tympani is lacerated in the course 
of an otitis, it almost always occurs at the moment of a strong 
expiration, as, for instance, when the patient sneezes. Such an 
effect from sneezing is rendered possible from the fact, that in a 
purulent otitis, the cells of the mastoid process are filled with 
secretion, and there is a hyperemia of its integument ; while 
even when there is a complete solidifying of this part of the 
temporal bone, there are still, immediately behind the cavity 
of the tympanum, certain hollow spaces still unfilled, and in 
a condition for containing air. It seems to me, that a perfo- 
ration of the membrana tympani, during an inflammatory 



140 SIMPLE CHRONIC AURAL CATARRH. 

process, more commonly proceeded from the above-mentioned 
cause than from a pressure of the secretion against the thin 
membrane. And the following fact goes to sustain the 
opinion — that is, that we generally find a fine long perfora- 
tion, not a round hole, as would proceed from the gradual 
bursting of an abscess, whose covering had been for some 
time under pressure and tension. 

We pass on now to the Eustachian tube, and we have 
already seen that the physiological duty of the tube is a 
double one. It has at once to transmit the secretion of the 
cavity of the tympanum downwards, in which the motion 
of its epithelium sensibly assists, and then to keep the air in 
the cavity of the tympanum and in the cells of the mastoid 
process in equal proportion with that without. "We have 
seen, furthermore, that the muscles of the tube have a consi- 
derable-share in the performance of this duty, and that they 
cannot do their work properly when they are " insufficient." 

This insufficience can be absolute, from degeneration of their 
structure, or paralysis of their nerve supply — the fifth pair — 
or from what often exists when the muscles are otherwise in 
a perfect condition, inability to perform their functions on 
account of increase of mucous or glandular secretion of the 
tube. The middle ear can only be in an entirely normal 
condition when there is no interference with the functions 
of its mucous membrane and muscles ; and vice versa, each 
abnormal condition of the Eustachian tube must have an 
effect on the cavity of the tympanum. I cannot speak often 
enough of the dependence of these parts, the one upon the 
other ; and I must so much the more attempt to impress its 
great importance upon you, and attempt to make it clear, 
since it plays such a part, in our view, in aural catarrh, while 
an opposite view is taken by the most of authors. 

Generally, all the parts of the middle ear are attacked simul- 
taneously with catarrh, which leaves tracks of its presence 
in the cavity of the tympanum, and on the internal surface 
of the membrana tympani. In some cases, however, it is 
localized in the Eustachian tube, and confined entirely to its 
membrane. 

As we have said before, this catarrh of the Eustachian tube 
must greatly affect the cavity of the tympanum, even when 



SIMPLE CHRONIC AURAL CATARRH. . 141 

the mucous membrane of the cavity does not participate in 
the morbid changes of that tube. The retained secretion 
of the middle ear is of minor importance, since in a normal 
condition it is very small in quantity. The interference of the 
exchange of air between the cavity of the tympanum and 
the pharynx is of much more importance, for the air already 
in the cavity will gradually be absorbed, and thus pressure 
only remain on the external surface of the membrana tym- 
pani ; this will become more and more pressed inward, and 
with this the ossicula auditus, as is shown by the ingenious 
experiment of Politzer, and thus a pressure on the labyrinth 
is made. If you will swallow repeatedly, with your mouth 
and nose closed, you will experience an uncomfortable feeling 
of fullness in the head, accompanied by deafness and noises 
in the ear. In a similar manner, though less marked on 
account of the gradual approach to this state of things,. 
the closure of the tube will manifest itself, and it is known 
that these symptoms appear with each severe cold. If the 
swelling should remain but for a short time, then the hearing 
will be restored in its integrity. So soon as the equality in 
the pressure of the air has been restored in front of and 
behind the membrana tympani, as often suddenly occurs in 
sneezing, yawning, or blowing the nose, the patient will 
then hear as well as ever, is freed from the unpleasant feeling 
of fullness, pressure, and noises in the ear. 

On the contrary, if the closure of the Eustachian tube has 
lasted for months and years, if the membrana tympani has 
been for a long time pressed inward, and the stapes against 
the vestibule, and thus a pressure exerted for the whole time 
against the tender structure of the labyrinth, while the two 
muscles, tensor tympani and stapedius, are not in a normal 
condition, while all these things have occurred, changes 
of structure will have developed, which do not disappear, 
even if the causes are removed. 

The most characteristic symptom of this described condi- 
tion of things is, that the membrana tympani is pressed 
regularly inwards and is everywhere, over its whole surface, 
concave, the color and density altered, although, as to the 
latter, it makes the impression of being thinned and atrophied, 
and the articulation of the incus is plainly visible. If the patient 



142 ■ SIMPLE CHRONIC AURAL CATARRH. 

presses air into the ear, or we blow in with the catheter, 
we will see the membrane go outward with considerable 
power, and then sink back again to its previous position. 
Wilde calls this condition " collapsed membrana tympani." 
This collapse is, however, less often a result of primary- 
weakness, a self-originating atrophy of the fibrinous portion 
of the membrana tympani, than a consequence of long-conti- 
nued, one-sided pressure exerted on the outer surface of the 
membrane, and thus, in the course of time, its equable 
condition has been altered ; whereby, as it seems to me, 
a thinning and atrophy of its fibrous structure has occurred. 
It is doubtless true, that such a state of things is also brought 
about and encouraged by abnormal adhesions of the mem- 
brana tympani, and by peripheral thickening of its mucous 
membrane. 

When, then, we meet with such a collapsed condition of 
the membrana tympani, we must consider all the possible 
modes of its origin. It can depend on any of the previously- 
named causes, viz. long-continued closure of the Eustachian 
tube, change of structure in the membrane itself on the 
formation of abnormal bands of adhesion. 

The cases where the catarrh plays a more independent 
part, and remains the concentrated point of' the disease, 
are very probably the least common. Generally, the catarrhal 
symptoms in the middle ear, if not the first in point of time, 
are the most important as regards the permanent affection 
of the hearing ; and if there be a swelling of the membrane 
of the Eustachian tube accompanying it, it is merely a coinci- 
dence on which, probably, depend the vacillating symptoms 
of the patient. Every one's Eustachian tube is more perme- 
able in dry weather, and less so in moist. 

This slight swelling of the mucous membrane, which pro- 
duces no^ symptom in a healthy individual, has, however, 
a disturbing effect on the ears of a person who has suffered 
for a long time from a chronic inflammation of this part, 
and whose Eustachian tube entrance is, consequently, very 
small. Therefore, it is well for such patients to press daily 
upon the ear, and thus assist in preventing complete closure 
from taking place. If we speak of chronic aural catarrh 
as " catarrh of the Eustachian tube," we ascribe too great 



SIMPLE CHRONIC AURAL CATARRH. 148 

an importance and independence to the tube and its affec- 
tions. The principal interference with the hearing depends 
chiefly on the localization of the affection in the middle ear, 
and on the wall of the labyrinth on the two fenestra. If we 
except the closure of the tube, which plays an important 
part, its affections are of quite transient importance. 

Prognosis of Chronic Aural Catarrh. — This is so far good, 
as we can reach the seat of affection, and act on the mucous 
membrane of the middle ear, by means of the catheter. But 
we see these favorable appearances only in two directions. 
We know, that in general we have no radical treatment 
for catarrhal processes in other mucous membranes than that 
we are now dealing with, and remains or residue processes 
are very common. Onlv too often there forms in persons 
who have at one time suffered from aural catarrh a locus 
minoris resistentice ; and thus, every cold, every slight cause 
of disease, has an effect on this part. There are some 
persons who need a continuous treatment, only to get rid 
of residues of these permanent affections. Another unfavor- 
able circumstance for the prognosis is, that the subjective 
symptoms are so few, the course of the disease so insidious, 
and the deafness appearing so unnoticed and slowly, that 
the greater number of patients notice it first after some 
degree has existed for a long time — it may be for a term 
of years. How much or how little can we do for a case 
of old and deeply-rooted catarrh ? 

You must know, gentlemen, that here, the case is about 
the same as with ancient affections of other organs.. We can 
do about as much for the ear, under these circumstances, as 
for any other part. The older the patient, the longer existing 
has been the affection, and the more morbid changes in 
structure have taken place in the cavity of the tympanum, 
the less will we be able to do for our patients. However, 
in many cases of long standing, which seem to look unfavor- 
able, much may be won by a long-continued local treatment. 
We must expect very little from our art, and be contented 
if we can check a process, and leave a certain amount of 
hearing, which, without interference, would have gone on to 
total deafness. Do not esteem this little too lightly, gentle- 
men, for it is something, when a patient, already suffering 



144: SIMPLE CHKONIC AUBAL CATAKEH. 

from ten to twenty years' deafness, which, without medical 
aid, would have gone on to complete loss of hearing, is re 
strained, and enough hearing left for the duties of life, 
even if with some inconvenience. 

Consider for a moment what the physician is able to do in 
other intensive affections of mucous membrane, although, for 
many years, the field of science in which he is working may 
have rejoiced in properly directed labor, and it may be an 
affection in which the patient seeks medical aid very early. 
Do you entertain a very sanguine hope for a patient who 
has suffered for a very long time from a declared catarrh 
of the lungs or of the bladder ? Do you not consider your- 
self fortunate when you have maintained the " status in 
quo ?" and will you not, even with the utmost care, often 
be unable to prevent the progress # of the disease ? Aural 
catarrh does not belong to the worst forms of disease as to 
prognosis, because, as a rule, we are able to check the 
progress of the affection. In more recent cases, we are 
able to say, that the condition can be greatly improved, and 
the prognosis, in general, would be altered, if the patients 
came to us earlier. In order that the condition of things 
may be changed, you, gentlemen, must do your part ; for, 
added to the few subjective symptoms which are excited 
by chronic catarrh, there is a want of intelligence among 
the people, and a want of physicians whom the people can 
trust in aural affections. Thus it is, that the affections 
are developed to an irremediable degree. If the public 
but learns that diseases of the ear, like other affections, may 
be cured in their beginning, but that the probability of im- 
provement diminishes as the disease advances, and when 
the time comes when there are surgeons enough who know 
how to examine and treat a patient with aural affection, then 
the prognosis of chronic catarrh of the ear will be entirely 
different from what it now is. 

^ If you wish to make distinctions, as to prognosis, in the 
different forms of aural catarrh, then, I would say, that my 
experience teaches me that the most unfavorable are those 
where the changes in the membrana tympani are diffused 
over the whole surface, and it is regularly thick, without 
any change in color. In such cases, when year-long, slowly 



SIMPLE CHRONIC AURAL CATARRH. 145 

developing thickening of the mucous membrane of the cavity 
of the tympanum, is indicated ; where a kind of sclerosis 
has occurred, we will be fortunate, if we succeed so far 
as to diminish the Tinnitus annum. If, however, there be 
a partial and circumscribed alteration in this membrane, 
especially of the adhesive variety, and the membrane ap- 
pears more of a white color, then the prognosis is often better 
than the other circumstances, age, and general condition of 
the patient would lead us to infer. The more, in general, 
the abnormal condition of the parts can be improved by 
the mechanical effects of the air-bath, the less morbid changes 
have taken place on the fenestra ovalis and rotunda, and 
the more prominent in the foreground is the morbid condi- 
tion of the Eustachian tube, the better will be the prognosis. 
In synechia of a high grade of development, which has gone 
on to an almost complete obliteration of the cavity of the 
tympanum, I have scarcely ever seen any improvement. 
A very unsatisfactory prognosis will also be made, when, 
with deafness, there also exist calcareous formations on 
the membrana tympani. Patients who, although they have 
a great loss of hearing, have not been affected long, who 
are getting worse, have a better prospect for treatment than 
those who, for years, have remained at about the same point. 
You should be guarded, however, in the first-named cases, 
in saying how much you can improve the condition. "We 
can never say what extension of the morbid process has 
been made upon the contents of the cavity of the tym- 
panum, and how much the labyrinth has taken part in the 
process. 

Some cases, and just those which are improved by a simple 
filling of the middle ear with air, have so far an unfavorable 
prognosis, in that they require the constant continuation 
of this practice. Such patients should be taught to, use the 
catheter themselves, in order always to be in a condition 
to blow in air, or allow others to do it. 

10 



LECTUEE XVI. 

TREATMENT OF CHRONIC CATARRH. 

Local Treatment — Air-Bath. — Steam. — Mechanical Methods of 
Dilatation. — Treatment of the Mucous Membrane of the 
Pharynx. — Cauterization. — Gargling, and its Mechanical 
Importance. — Excision of the Tonsils. — Observation of PatienVs 
General Condition. 

Gentlemen — Since we have studied the nature of aural 
catarrh, in all its variations, we will close the subject to-day 
with some remarks on the Treatment. 

This must consist in a correction of the altered condition of 
the mucous membrane, and an attention to the general health 
of the patient. The strictly local treatment can only be 
practised by means of the catheter. 

There are cases, and these especially occur in young people 
and children, when it is sufficient to set in motion the irritating 
mucus in the Eustachian tube and cavity of the tympanum, 
bringing the two surfaces of the tube away from each other, 
and thus render the free interchange of air possible between 
the cavity of the tympanum and pharynx. This purely 
mechanical effect of the air-bath is necessary in all cases 
in the beginning. But, further than this, we must attempt 
to affect the diseased membrane, and seek to change its 
morbid condition. This will be done chiefly by the vapor 
of water injected into the middle ear. So long as there are 
increased rattling sounds during the air-bath, and we believe 
there is an increased secretion, and a moist swelling of the 
whole mucous membrane, the fumes of muriate of ammonia 
will be of especial benefit ; their use being now practised with 
success in affections of the larynx and" trachea. The pain 
caused differs very much in different persons ; some only 
feel an unpleasant warmth, others' a sense of smarting : gene- 



TREATMENT OF CHRONIC CATARRH. 147 

rally, however, there are only pains of very short duration, 
partly in the ear, partly in the throat. If the patient says 
he only feels the vapor in his throat, we need not always 
conclude that it has not passed into the ear. The otoscope, 
and the subsequent examinations of the membrana tympani, 
where the vessels on the handle of the malleus are generally 
injected, after the application of the chloride of ammonium, 
tell, generally, a plainer and more correct story than the 
patient. We take uncrystallized ammonium muriaticum depu- 
ratum, and allow only a small stream of air to pass gently, 
filling the pump, and opening the faucet only halfway, so 
that the salt shall not enter in great masses, but in an infi- 
nitely minute, sublimated condition. How long each sitting 
should be, if each ear should be acted upon, cannot be 
answered except by referring to each individual case, after 
the first effect of the vapor is seen. Generally, the secretion 
is soon checked, the impermeability of the tube is removed, 
and a fuller and stronger stream of air passes into the ear. 
In older cases, the ammonia serves only as a preparatory 
remedy, by means of which a farther treatment is rendered 
possible, and that is by the means of the vapor of water- 
steam, — which must be used for weeks, and sometimes for 
months. 

Moist warmth is the most powerful softening agent and 
aid to resorption ; and the warm vapors are of great im- 
portance in treating the thickenings of the mucous membrane 
of the middle ear. We choose a high or low temperature 
for the vapor according to circumstances ; I generally use 
from 35° to 45° Eeaumer (Fahrenheit 110° to 133°). The 
warmer it is applied, the oftener we must allow pauses during 
its application, in order that the silver of the catheter is not 
too much warmed, and an unpleasant burning in the nose 
be caused. The mouth of the catheter is mostly felt in the 
nasal entrance, and I take care, in cases where I must use 
a high degree of heat, say 50° to 60° R., or where the patient 
is peculiarly sensitive, to guard the part by means of a piece 
of gutta percha, which is drawn around the catheter. The 
effect of the warmth is very much less marked in the pharyn- 
geal entrance to the tube and in the cavity of the tympanum 
itself. The time of a sitting, during which the vapor is 



148 TKEATMENT OF CHEONIC CATAEEH. 

partly drawn in with an interrupted, partly with a continu- 
ous, stream, is from five to ten minutes, and still longer. In 
many cases we are obliged to go back from vapor of water 
to that of muriate of ammonia, as we cannot always exactly 
say when any given case will be better affected by one or 
the other. 

I have made various experiments, in chronic cases, with 
different kinds of vapors ; and when I, perhaps, except iodine 
and acetic ether, I must choose vapor of water as the best. 
Among the preparations which I have used, are, besides the 
various ethers, sulphuric and nitric, chloroform, acetic acid, 
aceton, one of the products of the dry distillation of w T ood, 
acidum pyrolignosum, ol. terebinth., narcotic extracts, and 
all without any especial use. 

"We should not cease, however, to attempt to find new 
remedies, some one or other of which may be of great use 
in a particular case, and the effects of remedies on a mucous 
membrane can only be made known through a series of 
observations. 

I should speak of the vapor of carbonate of ammonia 
as another of the remedies which I have used, which is more 
irritating than the muriate, and of calomel, of which this is also 
true ; of camphor, which has an almost indifferent effect ; of 
gases, I have used carbonic acid : we can use this mixed with 
atmospheric air, or warm vapor of water. 

We have already seen, that all these applications must be 
made with a certain vis a tergo / that a compression pump, 
or the like, must be used if we would be certain that the 
air passes not only into the lower part of the tube, but also 
into the cavity of the tympanum itself. It is always advis- 
able to occasionally introduce an otoscope during the use of 
the catheter, in order to assure ourselves that the instrument 
has not been displaced. This precaution is doubly necessary, 
when we cannot fully rely on the intelligence of the patient 
who is holding the catheter. 

Yon will naturally find, that after the use of warm vapors, 
to which, perhaps, an irritating remedy, for instance tinct. 
iodine, is added, that considerable fullness of the vessels occurs 
in the mucous membrane, and that the patients will hear 
worse, the head is fuller, and they complain more of fullness 



TREATMENT OF CHRONIC CATARRH. 149 

in the ear, and noises in the head ; I would much prefer 
that this hyperemia should occur than that there should be 
no results, after such severe medication. If the artificially 
excited swelling of the membrane should affect the perme- 
ability of the tube, and the condition of the pharynx, which 
sometimes very unpleasantly occurs, we must use the simple 
vapor of warm water for a few days, with the simple air-bath, 
or muriate of ammonia, and direct the patient to press in air 
several times a day, by closing the mouth and nose, and making 
a strong expiratory effort ; and we should convince ourselves, 
before each application of the steam, of the permeability of 
the tube, by using the simple air-bath. From the above- 
named reason, we are seldom able to use acetic acid, which, 
otherwise, would be of great use. 

Having been convinced, from repeated observations, that 
people who have suffered for years from deafness, conse- 
quent upon chronic catarrh, have been improved from an 
attack of acute inflammation, I have sometimes endeavored 
to produce an acute artificial one. I have used for this pur- 
pose quite severe irritants, pure tincture iodine, concentrated 
acetic acid, which I forced into the cavity of the tympanum 
in a full stream. The pain and other symptoms of irritation 
were quite considerable, without my being able to see any 
results to the hearing. 

If we will now consider the condition which we find in the 
dead subject in chronic aural catarrh, we may learn from that 
what we may expect from our treatment. 

When, unfortunately, the whole canal leading to the mem- 
brane of the fenestra rotunda, is filled with a plug of connect- 
ive tissue, as I have found it, and described in my sections, 
or this membrane is changed to a thick, inelastic one, or to a 
calcareous plate, does it not indicate an operative procedure ? 
I am persuaded, that even in aural surgery, a wider field will 
be opened to operative experience. It is not yet time, in the 
present condition of this department of science, for the intro- 
duction of such ideas, and each step forward must be assured 
us by experiments on animals and on the dead body. E"o 
where is there so much humbug practised, and unscientific 
attempts made, as in this department ; and no where, both 
from lay and professional public, is medical treatment received 



150 TREATMENT OF CHRONIC CATARRH. 

« 

with so much distrust. "Whoever wishes to speak of the 
subject fairly, must admit this. 

Before we leave the subject of chronic aural catarrh, we have 
still to speak of mechanical dilatation. In cases where, after 
repeated air-baths, and also the use of the vapor of the muriate 
of ammonia, only a very weak stream of air passes into the 
ear, and that only with the aid of the act of swallowing, and 
when the narrowing of the tube does not depend on the 
swelling of the mucous membrane, but on an organized hyper- 
trophy of connective tissue, there is nothing remaining 
but the use of a sound of whalebone, or catgut. This 
must be in the shape of a blunt cone, and of the length of 
the catheter, with that of the tube added. It is well to use 
a catheter with a large angle of curvature, and to press it as 
much as possible on the nasal septum, so that the sound, 
protected by it, will be less likely to pass into the throat. So 
soon as the middle of the canal is reached, the patient will 
speak of a sharp pain in the ear, and when the sound comes 
to the last third in the change from bony to cartilaginous 
canal, where the passage is the narrowest, and where changes 
most often occur, the local pain is increased, and may 
extend to the teeth above and below. One patient spoke 
always of a severe pain in the back part of his head. If the 
sound will not pass further, withdraw it, and by repeated 
attempts try to get it in the opening. The very plain move- 
ment of the sound, in the moment when the patient makes 
the motion of swallowing, is very interesting. In most 
cases, after its withdrawal, the catgut, if it has lain for some 
time in the canal, will afford us a clear view of its peculiar 
spiral course, varying in different individuals ; sometimes 
it may be observed behind the membrana tympani. 

The narrowest portion of the Eustachian tube, isthmus tubce, 
has only a width of scarcely one millimetre ; therefore, we 
cannot use a sound which is any thicker. The whalebone 
sounds can be made of various thicknesses ; of course we 
begin with the thinnest, and increase gradually. I have, as 
yet, never seen, any emphysema of the cervical region result- 
ing from this sounding. In order, if possible, to avoid any 
such result, I forbid the patient from passing in any air for an. 
hour after. After a few passages of the instrument, the stream 



TKEATMENT OF CHRONIC CATARRH. 151 

of air and sound pass much more freely. JRau recommends 
sounds, dipped in solutions of nitrate of silver, and dried, in 
order to unite cauterization with dilatation. On the whole, 
this dilatation of the tube is not often necessary, but there are 
cases in which we cannot get on without it. 

I have sometimes succeeded with whalebone, when with 
catgut I did not. I have seen no results from medications 
applied to the external auditory canal, and on the external 
surface of the membrana tympani, or from a stream of carbonic 
acid gas, so often recommended at our springs, to be passed 
upon the ear, in chronic aural catarrh. Since Toynbee recom- 
mends the penciling the external meatus with a strong, and 
the membrana tympani with a weak solution of nitrate of 
silver, I considered it my duty to give it a fair trial. I have, 
as yet, seen no other result than that the penciled portion 
became black. As an adjuvant, we can paint behind the ear, 
with tine, iodine, or use the iodine in the form of a salve. 
(In all chronic affections of the external and middle ear, unless 
accompanied by otorrhoea, I believe counter-irritation behind 
the ear will be found a reliable agent. Its use, however, must 
be persistent and thorough, not allowing any intervals of non- 
irritation of the parts during the whole course of treatment.) 

AVe will now, gentlemen, go on to consider that which 
must never be neglected — the treatment of the mucous mem- 
brane of the pharynx. Nothing will do so much to retain 
a chronic hyperemia of the mucous membrane of the ear, as 
an old congested condition of the same membrane in the 
pharynx. 

Cauterizations of the affected membrane do excellently 
well. The solid stick adapts itself better in granulations, or 
in very intense general swelling ; but even in the last-men- 
tioned cases we should not cauterize too large a portion at 
once, lest there be trouble in swallowing, and the effect on 
the larynx and trachea be too great. We should content 
ourselves with touching one or two spots, especially on the 
side of the pharynx, where the already described red swellings 
extend from the Eustachian tube. In order to be able to 
touch the upper part of the pharynx with the caustic, I use a 
caustic holder, such as is used in cauterizing strictures of the 
urethra, being a laterally opening tube, at the end of a strong 



152 TREATMENT OF CHRONIC CATARRH. 

silver wire. This is introduced through an ear catheter. It is 
especially useful for swellings, such as rhinoscopy shows often 
exist near the entrance of the Eustachian tube. 

I would generally, however, advise you to use solutions of 
nitrate of silver, at a strength of from twenty to fifty and 
even sixty grains to the ounce. For the lower portion of the 
pharynx, that opening into the mouth, a camel's hair pencil 
is best adapted for conveying the solution ; and for other 
parts, a whalebone, with a piece of sponge attached, bending 
the bone according to the part we wish to touch, and thus we 
are able, while the patient takes a long breath, not only to 
reach the part near the tube, but also even to the base of the 
skull, if we go cito et tute. , 

The irritation of such a cauterization of the upper part of 
the pharynx is very various ; the pain caused is seldom of very 
long duration, and is most marked in swallowing. A consi- 
derable mucous secretion very often results, or an increased 
flow of saliva ; sometimes severe fits of sneezing — very rarely 
hemorrhage from the lungs — for a little time, small quantities 
of blood are mingled with the expectorated matters. In a 
case where the sponge had been directed extremely towards 
the mouth of the tube, a marked increase in the hardness of 
hearing was noticed for some hours after, caused by an increased 
congestive swelling of the mucous membrane. It is seldom 
necessary to gargle the mouth with cold water after such a 
cauterization. The change in the pharyngeal membrane, after 
cauterization, occurs very rapidly ; sometimes after one or two 
applications. It is to be applied daily, or at longer intervals, 
according to circumstances. 

Gargling is of great benefit to the membrane, partly with 
cold water, partly with prepared gargles. I make them more 
commonly from alum or iodine. 
R. 

Alum pulv. 3 i. — 3 ij. 
Aq. distillat. § viij. 
Spts. Tin. gall. 3i. — 3iij. 

M. 
This addition of brandy covers the astringent, unpleasant taste 
of the alum, while the common honey and sugar mixtures are 
only unpleasanter. 
Gargles of iodine are peculiarly adapted to children, when 



TREATMENT OF CHRONIC CATARRH. 153 

there is a severe swelling of the glandular portion of the 
mucous membrane. 
R. 

Tr. iodin, 3i. 
Potass, iodid. 3ij. 
Aq. distillat. § viij. 
Spts. vin. gallici 31 — 3 iij- 
M. 

These iodine gargles have more than a local effect on the parts. 
I have seen goitre considerably decreased in size by its use, 
and ladies have called my attention to a growing smaller of 
the figure, a slight decrease in size in the breasts. 

In cases v where secondary syphilis manifests itself in the 
form of ulcers on the soft palate, on the tonsils, and on the 
edge of the tongue, in the form of papules, or ulcerations, the 
tincture of iodine gargle, and also one with hydrarg. bi-chlorid. 
gr. i-iij to aquae § viij., will be found beneficial. 

Besides these, there is a variety of preparations which can 
be used with profit. 

According to my view, gargles do more good to the parts 
from their subsequent effects, than from those when directly 
in application. If we examine the structure of the mucous 
membrane we will be convinced, that the layer of it, richest 
in mucous glands, not only lies over the muscular fibres, for 
which reason these glands must be greatly affected by each 
muscular contraction, but also, that in many places, especially 
in the soft palate, the arrangement of the muscular fibre is 
such, that it passes around, envelopes, and grasps many of the 
glands. Every energetic contraction of the muscle, then, 
must make a certain pressure on the glands, and violent 
swallowing motions will assist greatly in ejecting their con- 
tents, the mouths of the glands being quite patulous, especially 
in the uvula, and anterior surface of the soft palate. 

If we wish to use gargles, they must be used properly. As 
generally used, the patient standing, and with the head thrown 
backwards, and moving the gargle about, with the well-known 
roaring sound, no parts beyond the teeth, the dorsum of the 
tongue, with the uvula, and most prominent portion of the 
tonsils, are touched by the gargle, and the whole muscular 
action consists of a strong to and fro motion of the uvula. In 
such a manner of gargling, there can be no such thing as 



15i TREATMENT OF CHRONIC CATARRH. 

touching the posterior pharyngeal wall, and energetic muscu- 
lar contraction. In order to effect this, gargling must be 
practised in a different manner. Let the patient sit, or, better, 
lie down, with the head thrown back as far as possible, and 
taking the gargle in the motion, continue to make repeated 
swallowing motions, without, however, admitting the fluid 
into the oesophagus. Try this method of gargling in your 
own person with simple water, and you will convince yourself, 
by the sensation experienced, that many more parts are 
brought in contact than by the commonly practised noisy 
method ; and you will furthermore find, that a more or less 
considerable amount of mucus is ejected during or immedi- 
ately after the act, if the membrane is in a congested condi- 
tion. Frequent gargling, if only with cold water, is an excel- 
lent remedy in chronic pharyngeal catarrh. Kot only in that 
every abnormal collection of secretion is prevented, but also 
that the normal secretion is improved. With this there also 
occurs a gymnastic exercise of the muscles involved in the 
swallowing act. Every striated muscle increases in volume 
and power, by means of constant and methodical exercise, 
as you all can see in gymnasiums, the exercises of the Turn- 
ers, etc. 

ISTow but turn this result of our general experience to the 
muscles of the throat, you will see the value of such exercises 
when you consider at the same time the importance of these 
muscles for the functions of the Eustachian tube, and the 
normal condition of the middle ear ; and remember that in 
chronic pharyngeal catarrh, a great power is necessary for 
the muscles of the tube, a power which can only be obtaioed 
when the muscles have been developed in size and power. 
You will see, if you remember all this, that gargles and 
frequent action of the muscles used in swallowing, are the 
best remedies for insufficiency of the muscles of the tube, 
which, as we have seen, occurs very often in aural and pha- 
ryngeal catarrh. 

You see, gentlemen, that I esteem gargles, especially from 
a mechanical, or, if you please, a gymnastic point of view ; 
and I assure you these are no theoretical and a priori specu- 
lations ; but I have seen important results from simple gargling 
with cold water when continued for a long; time. 



TREATMENT OF CHRONIC CATARRH. 155 

Patients who have suffered from noises in the ear and diffi- 
culty in swallowing from long-continued pharyngeal and aural 
catarrh, who, with the slightest cold, have pain in the throat, 
and increased secretion in the fauces, and an addition to their 
loss of hearing, who awake every morning with a burning dry 
larynx, heavy head, and a fullness in the ear, and who could 
remove the collected mucus only with much difficulty, such 
patients I have seen, for a greater part, freed from all these 
symptoms, become in every way better, and the affection 
of the ear brought to a stand-still. 

This gargling should be done at least twice a day — early in 
the morning, and just before going to bed. In connection 
with this, the patient can also snuff water into the nose. 

The mucous secretion in the upper pharyngeal space is so 
considerable in many persons, especially around and behind 
the mouth of the Eustachian tube, that with almost every 
introduction of the catheter a mass of greenish gray mucus 
will be drawn out, and a loud rattling sound excited at the 
beginning of the passage of air. In such cases, I have seen 
important results from repeated injections of cold water into 
the nose, diminishing the foetid smell from the nose and pha- 
rynx. 

If the nose be injected with the ordinary ear syringe, the 
posterior and lateral wall of the pharynx will be touched 
too little, and many patients have a severe pain in the fore- 
head, especially if the opening of the syringe be directed 
upwards. I have, therefore, caused a silver tube to be made, 
of the same length with the catheter, whose end is closed, but 
the sides, for a little distance from the extremity, perforated 
with little holes. By means of this instrument, we are able to 
reach the wall of the pharynx more conveniently and safely. 
In order that the patient can better apply the syringe himself, 
the outer extremity is bent nearly to a right angle. The intro- 
duction of such a tube is easily learned even by the least in- 
telligent. The water will generally pass again out of the nose. 
Many patients have told me, immediately after the injection, 
that the head felt much freer, and that the noises in the ear 
were sensibly diminished ; and speak often of astonishingly 
large quantities of mucus which have been removed in this 
manner. 



156 TEEATMENT OF CHRONIC CATARRH. 

If the tonsils be abnormally large, 
they must be removed, or else the 
treatment will have no lasting 
effect. Hypertrophied tonsils, if not 
themselves the seat of frequent in- 
flammation and abscesses, retain 
the chronic congested condition of 
the pharynx by their presence, since they are like 
foreign bodies, and prevent the normal action of the 
muscles of the throat ; moreover, they press the broad 
portion of the soft palate upward, and thus, but not 
in a direct manner, as is generally believed, press 
the anterior lip of the Eustachian tube against the 
posterior. I have only seen improvement in the hear- 
ing in aural catarrh, after the removal of the tonsils, 
only in recent cases, and in children ; but even in old 
cases, the chronic catarrh of the pharynx is very much 
improved, and it loses the inclination to an increase of 
the ear affection. But I advise you to excise the ton- 
sils when they are large, even if they exercise no effect 
on the hearing power. 

Setting aside the fact that a removal will guard the 
ear from any evil consequences on account of their 
size, enlarged tonsils are a hindrance in respiration, and 
thus have a considerable effect on the whole constitu- 
tion, especially on the development of the chest. 
They may be excised with the Fahnestock instrument. 
Eemove only the portion of the tonsil which reaches 
out in front of the arch of the palate, since, without 
this precaution, you may have severe hemorrhage, 
which you cannot check. The end of the tonsil being 
thus cut off, they will afterward fully shrink away. 
Incisions, scarifications, are only useful in fresh cases, 
and in the evacuation of abscesses. Penciling with 
iodine, nitrate of silver, etc., even when persisted in for 
Fig. 10. weeks, according to my experience, produces no result. 
Finally, gentlemen, to take a comprehensive view 
of the general condition of the patient suffering from chronic 
aural catarrh, we shall not be able in each case to find all the 
symptoms which I have detailed to you. 




TREATMENT OF CHRONIC CATARRH. 157 

Make the patient attentive to each influence which works 
favorably or unfavorably on his condition. If the patient 
works for a whole day with bended head in an over-heated 
office or counting-room, perhaps never enjoying more than 
half an hour fresh air in a week, in the evening smokes and 
drinks in a restaurant or bar-room, sleeps in a small unventi- 
lated room, he has very many opportunities to develop an 
aural catarrh to its utmost, and you can never be able to 
lessen the disease, whatever you may do. Fresh air, and exer- 
cise in it, clothing adapted to the weather, woolen or silk next 
to the body in winter, care that the feet are dry and warm ; 
moreover, he should avoid whatever interferes with the free 
circulation of the blood, tight articles of dress, costive bowels, 
and long-continued sitting in a bent position. The use of 
mineral waters, carefully chosen according to the patient, are 
of great service in connection with local treatment. 

Cod-liver oil, with a mixture of ol. terebinth., seems to me to 
lessen the tendency to aural catarrh. Take 3ss. to 3i. to § i. 
of cod-liver oil, and disperse the taste with a little oil of cinna- 
mon or sarsaparilla. Attention to the condition of the skin is 
very important ; in the cold season, a warm bath weekly ; 
in summer, cold ones — guarding the ear from the entrance 
of the water. 

Salt- baths seem to do such patients harm. Water cures, 
where so much is done by rubbing and packing in water, and 
which many persons believe to be a panacea, are to be avoided. 
They are the frequent causes of injury to the membrane of the 
middle ear. 

From the ''London Medical Times and Gazette," Aug. 22, 1863. — Foreign Cor- 
respondence. Berlin. 

" Some time ago, a committee was chosen by the Medical 
Society of Berlin for the purpose of settling certain pending 
questions in aural surgery. The committee consisted of Messrs. 
Virchow, Krieger, Leyden and other well-known men, and 
have quite recently reported the result of their experiments, 
which have been conducted in the most unexceptionable 
manner. 

" If air is blown into the Eustachian tube by means of a 
wide silver catheter, the membrana tympani being intact, this 



158 TREATMENT OF CHRONIC CATARRH. 

air does not penetrate into the cavity of the tympanum, and 
it is equally impossible to inject, by this method, any consider- 
able amount of liquid into that cavity, even if the permeabi- 
lity of the tube has been proven by previous sounding and 
auscultation ; but both air and liquids may be injected, if a fine 
elastic catheter is introduced up to the osseous part of the 
Eustachian tube. The sounds, which are heard on injecting 
air, are only produced when the latter method is adopted, and 
in the cavity of the tympanum itself, while such sounds as are 
perceived on using the ordinary silver catheter are most likely 
caused within the pharyngeal end of the tube. A change in 
these latter is due to an impediment in the conduction of 
sound, and we may find out therefrom whether the impedi- 
ment is movable or immovable, but it does not give us any 
bints as to any changes that may have taken place in the 
coats of the tube or the cavity of the tympanum. 

" It is impossible to decide at present, whether we may by 
blowing in air with the fine catheter succeed in removing free 
effusions from the cavity of the tympanum. It is settled beyond 
doubt, that liquids may, through the catheter, be introduced 
into the cavity of the tympanum. The diagnostic and thera- 
peutic value of sounding can therefore not be doubted." 

(I have thought it well enough to insert the above, which 
has just come to my eye, its conclusions being so opposed to 
those of Drs. Troltsch and Kramer — in fact, to those of all the 
continental aural surgeons. 

I have not been able to obtain the original report, and con- 
sequently cannot know the nature or manner of conducting 
the experiments on which the conclusions are based. 

It is of no importance as to what 1 believe, when such 
names as Yirchow are in the question ; yet I cannot help stat- 
ing that I believe there is a fallacy somewhere in the reason- 
ing, which concludes that air cannot enter the Eustachian canal 
and thus go on to the cavity of the tympanum through a silver 
catheter whose beak is in the pharyngeal orifice of the tube. 

The report says : " If air is blown, etc." This may be so 
worded, as to avoid saying, « if air be pumped," as Troltsch's 
method is ; but in either case, I am skeptical as to the value of 
the report as here presented, or as to the correctness of the 



TREATMENT OF CHRONIC CATARRH. 159 

conclusions, founding my belief on the aural practice I have 
seen in the hands of eminent surgeons, and- on my own recent 
experiments. I cannot believe as yet, judging from my own 
sense of hearing, that air does not enter the cavity of the tym- 
panum, when blown through the silver catheter. 

With Dr. Yon Troltsch's high estimate of the therapeutic 
value of the catheter, I am by no means in full accord, 
although I have not thought it well to contrast my crude and 
comparatively short experience with his carefully considered 
opinions, the result of years of special practice. 



LECTUEE XVII. 

ACUTE OTITIS INTERNA, OR ACUTE PURULENT CATARRH. 

General Remarks as to the Different Forms of Acute Otitis In- 
terna. — Is often Overlooked, or not Properly Regarded. — Case 
of Paracentesis of Membrana Tympani. 

Gentlemen — The inflammation of the middle ear, to which 
we have confined our observations up to the present time, was 
the simple or mucous catarrh. As is the case with all inflam- 
mations, this catarrh soon passes more into the interior of the 
tissues, becomes interstitial, and causes a thickening of the 
parenchyma, and soon also declares itself, in connection with 
the swelling and thickening of the tissues, by an increase of 
secretion, an exudation, if you choose to call it so. This pro- 
duct of inflammation in a simple aural catarrh consists of 
mucus and of conglomerated broken epithelium cells, which 
last is especially found in great masses in the ciliated epithe- 
lium of the Eustachian tube. As is well known, if this inflam- 
mation go on to a higher grade, it leads to a preponderating 
development of free cell- formation, to discharge of pus upon 
the inflamed mucous membrane. 

Observations upon the living and dead subject teach us that 
purulent catarrh also occurs in the middle ear, although much 
less often than the mucous catarrh, and that it occurs in two 
forms, acute and chronic. The inflammatory product, besides 
containing the puriform element, also contains mucus and epi- 
thelial masses. Since, as a rule, the inflammatory products of 
mucous membrane are of a mixed character, the name puru- 
lent or mucous catarrh only indicates that either one product or 
the other is in excess. Whether croupic or diphtheritic inflam- 
mations tilso appear on the mucous membrane of the middle 
ear, I do not know ; I have as yet not observed any such cases. 
I examined, in two cases, the middle ear of children, who died 



ACUTE OTITIS INTERNA. 161 

from laryngeal croup. In one case the membrane was only 
hypergemic, in the other it was greatly swollen on each side, 
and the cavity of the tympanum full of pus. I found no evi- 
dence of fibrinous exudation in the canal or cavity of the tym- 
panum, acute purulent catarrh of the middle ear, or acute otitis 
interna. 

We often find evidences of this disease on the dead body in 
children ; then we observe it as a participant and consequence 
of the exanthemata, measles, scarlet fever, and small pox, also in 
typhus fever and consumption. Furthermore, it occurs from a 
chronic inflammation of long standing rising to an acute form. 
Under very unfavorable circumstances, as to the patient, or 
improper treatment, acute simple catarrh may be developed 
into the purulent form. Acute purulent catarrh also occurs in 
weakly scrofulous constitutions, which are disposed to purulent 
formations after injuries, or impressions which in healthy per- 
sons would have only caused a simple catarrh. 

This affection has heretofore been described by most authors 
as acute inflammation of the membrana tympani. The 
symptoms are very similar to those in acute simple catarrh, 
but are much more severe, and the general condition of the 
patient much more disturbed. The pain, which is generally 
very intense, extends from the ear over the whole side of the 
head, and increases with every movement ; it becomes unbear- 
able, if the patient attempt to walk on any hard substance. 
The immediate neighboring parts are generally somewhat infil- 
trated with serum, somewhat swollen and sensitive ; there is also 
a severe burning feeling felt in the depth of the ear in most 
cases. The febrile condition is so great as to often extend to 
delirium and stupor. 

You will see that such symptoms as these, occurring in an 
exanthema, or typhus fever, and which can only be referred to 
the ear, will be little observed in consequence of the danger 
from the general condition of the patient, and in their begin- 
ning probably never referred to the correct source. The aural 
surgeon does not often, therefore, see these cases in their inci- 
pient stages, if we except those cases in which an ancient 
purulent catarrh, with perforation of the membrana tympani, 
suddenly becomes acute. 

The error which I called your attention to in a former lec- 

11 



162 ACUTE OTITIS INTERNA. 

tore — that is, confounding an acute mucous catarrh with an 
inflammation of the brain, may be also fallen into here ; for 
there is always, in acute purulent catarrh, a hyperemia of the 
dura mater, lying over the petrous portion of the temporal 
bone, and a proportionate effect on the sensorium. 

So long as no purulent discharge occurs, the general condi- 
tion of the patient prevents any particular attention from 
being paid to the ear ; and the delirious or somnolent patient 
is in no condition to indicate the seat of his sufferings. " The 
common exit of the process is perforation of the membrana 
tympani, with which the pain is very much diminished, and 
a purulent discharge takes place, if there has not already been 
a participation of the external auditory canal in the process, 
and an otorrhoea from this part. 

There is often developed, at the same time with the purulent 
inflammation of the cavity of the tympanum, an acute otitis 
externa, proportionate to the intense hyperemia, in which all 
the structures are found. According to several sections, which 
have been made in typhoid fever, the labyrinth appears also to 
be in a state of congestion.* 

In cases where a* chronic otorrhoea, with perforation of the 
membrana tympani, increases to an acute inflammation, the 
discharge is often suddenly lessened, or disappears entirely. 
This symptom is often incorrectly interpreted. 

This acute inflammation does not occur, because, as a result 
of a certain treatment, or any accidental coincident injury, 
cold, blow on the head, the secretion has been diminished, or, 
as some are accustomed to express themselves, " driven in," but 
on the contrary, the discharge, which has been previously pro- 
fuse, has become less, after an occurrence of an acute inflam- 
mation of the membrane furnishing the secretion, just as we 
can see the secretion diminished in a chronic catarrh, which 
has suddenly gone on to an acute stadium. 

* The best brochure on diseases of the ear occurring in typhus fever is from Dr. 
Hermann Schwartze. See " Deutsche Klinik," 1861, Nos. 28 and 30. 

According to Dr. S., there are three processes forming the origin of ear-affections 
in this disease. 

1. Purulent catarrh of the cavity of the tympanum. 

2. Catarrh of the pharynx with closure of the pharyngeal end of the Eustachian 
tube. 

3. Cerebral deafness, due perhaps to the poisoning of the blood. 



ACUTE OTITIS INTEKNA. 163 

Simple chronic catarrh, occurring in typhus fever, as in scar- 
latina and roseola, is quite common, and it is possible for it to 
run its course without any perforation of the membrana tym- 
pani, leaving only a swollen and congested condition of the 
cavity of the tympanum behind ; and so also the purulent 
catarrh may run its course, and leave no other residue. 

The most severe and dangerous form of the disease of which 
we are now speaking, is that in which there is such a power of 
resistance on the part of the membrana tympani, that the ab- 
scess cannot be discharged by its perforation. There are a num- 
ber of such cases on record, where, after the most terrible 
agony and severest symptoms, the inflammation extended to 
the membranes of the brain, and death quickly followed. 

We cannot know how often such cases occur, unless there be 
an examination of the ear after death. 

The perforation of the membrana tympani, therefore, may be 
sometimes considered as a favorable turn in the condition of 
things ; yet, even if an exit thus be formed for the pus, the dis- 
ease can still go on to a fatal result. 

This most often occurs in children, after one of the exanthe- 
mata. Later on, we will describe such a case in detail. 

The objective symptoms, in the beginning of an attack of 
acute purulent catarrh, are similar to those of a severe case of 
simple catarrh. The plane of the membrana tympani is altered, 
by the pus which has collected behind it, which bulges or 
pushes out some parts of its surface. Single vessels are not 
often to be seen, but a fine red appearance, indicating the 
hyperemia of its mucous surface, is mingled with its dull gray 
color. Sometimes single red spots (extravasations) can be se.en 
on it. In severe cases the mastoid process is painful and sen- 
sitive, and has an infiltrated, shining, red appearance. Exam- 
ination also often reveals a considerable swelling and redness 
of the pharyngeal mucous membrane, and the Eustachian tube 
will be found impermeable. 

Prognosis. — This is more unfavorable than in the acute form 
of simple catarrh. 

Yery few physicians can bring themselves to pay the least 
attention to the ear, in the constitutional diseases of which we 
have been speaking ; and they are the very ones in which its 
functions are most apt to be disturbed, ^Never are ear aflfec- 



164 ACUTE OTITIS INTERNA. 

tions so completely disregarded and placed in the background, 
as in those affections which confine a patient to bed. How 
many trouble themselves about the consideration of the ear in 
typhus fever, in tuberculosis, or in scarlet fever ? An Ameri- 
can surgeon (Dr. Edward Clark, of Boston) says, in an excel- 
lent article on "Perforation of the Membrana Tympani, its 
Causes and Treatment" {American Journal of Medical Sci- 
ences, Jan., 1858) : " So necessary is a careful attention to the 
ear, during the course of an acute exanthema, that every phy- 
sician who treats a case, without careful attention to the ear, 
must be denominated an unscrupulous practitioner." How 
severe this must sound to the most of German physicians ! It 
is certain that if every physician were to inform himself of the 
condition of the ear, as well as of the skin and kidneys, pulse 
and bowels — I will not insist that the ear should be examined 
with a speculum — we may merely inform ourselves as to its 
condition in a general way — if this were done, I say, many a 
child would not be deaf and dumb, and many incurable cases 
of deafness, and many life-long otorrhoeas would be avoided. 

There is such a number of acute diseases in which the ear is 
also affected, that the physician should always examine as to its 
condition, without waiting for the patient to announce his 
affection. 

Even with the most careful attention, and when the special 
symptoms lead us to take every care for the ear, we will some- 
times be unable to prevent the perforation of the membrana 
tympani. However, there will not be so much lost as if it had 
been entirely neglected, and there is still left a wide field for 
surgical assistance to prevent the otorrhcea from becoming 
chronic, and further consequences. 

Treatment— This must be decidedly antiphlogistic. Ac- 
cording to the general condition of the patient, we must use 
local depletion — placing a number of leeches around the mea- 
tus, so that the hyperemia may be reduced and the inflamma- 
tory process weakened. The severe pain and tension will be 
relieved by often filling the meatus with warm water. When 
the otitis, as is often the case in measles and scarlet fever, is 
accompanied by considerable inflammation of the pharynx, or 
this has been the origin of the whole process, the greatest 
attention must be paid to this. Apply cold water to the neck 



ACUTE OTITIS INTERNA. 165 

(or better, large, frequently-changed flax-seed poultices) ; cause 
the patient to gargle frequently, if possible ; cleanse the naso- 
pharyngeal cavity by injections ; and, if necessary, cauterize 
the throat with the nitrate of silver. 

(I am of opinion that in this and all other acute inflamma- 
tions of the mucous membrane, of the mouth, throat or larynx, 
the greatest amount of good will be experienced by the use of 
the inhalations of the vapor of some aromatic herb — catnip, for 
instance — or of simple warm water. In burns of the throat, 
from the inhalation of steam, in incipient oedema glottidis, in 
aphthous Ulcers of the mouth, I have seen the pleasantest 
results from this simple remedy. Dr. Gurdon Buck, the distin- 
guished senior attending surgeon of the Xew York Hospital, is 
in the habit of advising this for some of the cases to which I 
have alluded, and I am persuaded that it will be found equally 
efficacious in affections of the pharynx.) You must not con- 
sider this as a too energetic treatment, but remember that the 
life and happiness of the patient depend upon your promptness 
and care. 

Aural inflammation, in scarlet fever and measles, furnishes 
the greatest number of the inmates of deaf and dumb asylums, 
as well as a large proportion of our cases of deafness, of a high 
grade, in consequence of the readiness of the ear to participate 
in the exanthemata, and, as we must confess, from the com- 
plicity of the physician in neglecting the complication. 

In cases where the inflammation and pus formation is consi- 
derably advanced, and where we will probably not be able to 
prevent the perforation of the membrana tympani, when per- 
haps this result is wished for, we can encourage the suppura- 
tion by the application of warm poultices to the ear, or a para- 
centesis of the membrana tympani may be performed, where it 
is most prominent. In one case I was able to see the sudden 
improvement which occurred after such a paracentesis, without 
any discharge of pus. 

A woman working in a factory, 27 years of age, applied 
to me. After having suffered for ten days with a very intense 
pain in the ear, with transient discharges, I examined the mem- 
brana tympani, and observed a spot like a blister from a burn, 
about as large as a pea — such a one as you may see if the pa- 
tient has burned the membrane by a too warm ear-wash. This 



166 ACUTE OTITIS INTERNA. 

could not have happened in this case, since the patient had put 
nothing at all in the ear. The remaining portion of the mem- 
bran a tympani had a dense reddish-gray appearance. There 
was great pain in the ear and the mastoid region, the latter 
being reddened, temperature increased, and sensitive on pres- 
sure. I opened the blister immediately, with an instrument 
such as is used in paracentesis of the cornea, and evacuated a 
drop of serum. At this moment the patient breathed freer, 
and declared that the pain had almost entirely disappeared ; 
and what was in the highest degree remarkable, the mastoid 
process was less sensitive to pressure, and the patient ena- 
bled to open the mouth, which she was before unable to do. 



LECTURE XVIII. 

PURULENT CATARRH EST CHILDREN. 

Up to this time only known through Pathological Study. — An 
attempt at an Explanation, and its Practical Value. 

Gentlemen — I am about to speak to you of a form of puru- 
lent catarrh, which I am acquainted with only from post-mor- 
tem evidences, and which, as seen in the living, I must leave 
to those who have abundant opportunities to study the diseases 
of children. In the course of my examination of the normal 
and pathological anatomy of the ear, I happened accidentally 
on a peculiar condition in the ears of very young children, and 
which excited my attention the more, in that I observed it so 
frequently. In the greater number of auditory apparatus of 
children, which I have had the opportunity of examining, 
forty-eight petrous bones of twenty-five children (when I ex- 
cept one case of caries of the temporal bone, on each side), I 
found, in forty-six bones belonging to twenty-four children, the 
middle ear normal thirteen times — the remaining thirty-three 
ear6 of seventeen children were affected with purulent catarrh 
of the middle ear. The cavity of the tympanum, the upper 
portion of the Eustachian tube, and the cells of the mastoid pro- 
cess, were filled with a greenish-yellow, sometimes a species of 
creamy substance, showing evidences of being pus — and so 
proving to be, under the microscope. It appeared composed 
of roundish cells, with a quadrilateral nucleus or nuclei, which 
were often visible without the use of acetic acid. The clouded 
appearance of the cells cleared up on the use of the acid, but 
contained, besides, little fat cells. These collections of pus 
filled the whole of the space which the swollen mucous mem- 
brane had left. The membrane was always in a very hy- 
peraeruic condition, and occasionally there was a net of very 
delicate vessels, and the membrane was so hypertrophied that 



168 PURULENT CATARRH IN CHILDREN. 

the ossicula-auditus were imbedded in it, and their outlines 
scarcely to be made out. The mucous membrane of the mem- 
brana tympani also appeared slightly infiltrated, and covered 
over with a net-work of vessels. The membrane was never 
perforated or in a state of ulceration. 

With these appearances there also appeared, in eight cases, 
and always in cases where the contents were of a milkish con- 
sistency, peculiar red bodies, from the size of the point of a 
needle to that of a hemp seed, which were quite hard in feel- 
ing, and were firmly attached to the mucous membrane. On 
nearer examination, they proved to have a richly vascular cor- 
tex, and an internal structure, sometimes of granular-like fat, 
now of cells. All other explanations are wanting as to the 
nature and origin of these puzzling bodies, to which I know no 
analogous structures. 

The bodies of which the examinations were made were taken 
without choice, as I could obtain them during the space of 
three years and a half, partly from the city and partly from 
the Lying-in Institution, in connection with the Medical 
School in Wurzburg. 

The youngest child was seventeen hours old — the oldest, one 
year. Of the children with a normal middle ear, two were 
fourteen days old, one seventeen hours, one four days, and the 
remaining three, six and eleven months, respectively. The 
bodies were often such as were furnished to the students for the 
study of normal anatomy, since in the post-mortems which 
had been held, the immediately affected portions were the only 
parts examined ; twelve were of this class. The other post- 
mortem appearances were various, corresponding to the con- 
dition in life of these half-starved, poorly-cared-for children. 
The diseases of which they died were atrophy, inflammation of 
the bowels, partial collapse of the lung — bronchitis. There 
was venous hyperemia of the coverings of the brain in almost 
all the observed cases, and congestion of the brain substance. 
In those cases in which there was no pus in the cavity of the 
tympanum, there were no other pathological appearances. 
Thus much for the facts. 

Since, in our school in Wiirzburg, we do not often have an 
opportunity of examining older children, I must leave to others 
the work of ascertaining if these appearances obtain in like 



PURULENT CATARRH IN CHILDREN. 169 

proportion in children of larger growth. I am in possession of 
one history of a case of an older child, for which I am indebted 
to the kindness of my honored friend, Professor StrecJceisen, in 
Basle (I take the liberty of somewhat condensing the case, 
which Dr. Troltsch gives in full, on page 177 of the original of 
this work) : " A well-developed, healthy child, six years of age, 
after returning from a walk, was seized with headache, heavi- 
ness, and bilious vomiting. After a restless night, on the fol- 
lowing day the symptoms disappeared. On the evening of the 
second day, same symptoms return, surface heated, pulse 130 — 
all the appearances of congestion of the brain. Treatment, 
leeches between lower jaw and mastoid process, cold applica- 
tion to the head, cathartic. Symptoms disappear, and do not 
return for three or four days. Fifth day, all the symptoms of 
cerebral congestion reappear — restlessness, disposition to weep- 
ing, anxious visage, head hot, slow drawing back of the tongue, 
etc. Blood was taken from the Schneiderian membrane, cold 
applications to head, and cathartic of calomel. Symptoms again 
disappear. 

6th day. Gradual symptoms of cerebral pressure began to 
appear, drowsiness, some difficulty in waking, remaining till 
7th day, when pouring cold water over the head, seemed to 
have somewhat revived the patient, though not fully. 

8th. Paralytic symptoms appeared. 

9th. Increased, and on 

10th. In the morning she died. 

Sectio Cadaveris showed serous infiltration and congestion 
of the brain, swelling of brain substance, and consequent pres- 
sure. Both lateral sinuses filled with coagula. Cavity of the 
tympanum, and mastoid cells, on both sides filled with pus. 
Mucous membrane of the ear greatly injected and swollen. 
Membrana tympani slightly sunk inwards. 

The following facts are especially remarkable in this case. 

I. The very slight prominence of the pain in the head on 
the first and second day. On the reappearance of the affection 
on the fifth day, this symptom appeared, accompanied by sob- 
bing and crying. 

II. Entire want of convulsive symptoms during the period of 
irritation, rapid progress of the cerebral pressure, and paralysis. 

III. Entire absence of pain referred to the ear, although, 



170 PURULENT CATAKRH IN CHILDREN. 

in this respect, no special observation was made ; yet so much 
is certain, that the little patient spoke of no such pain ; and on 
the sixth and seventh days heard perfectly well ; at least, in the 
lucid moments, in conversation with its brothers and sisters, it 
gave clear answers. 

There were no evidences in the petrous bone to prove the 
origin of the affection in the ear, but the inflammatory results, 
in the cavity of the tympanum, had reached the greatest degree 
of development. It is to be hoped that physicians will inte- 
rest themselves in these cases, and by means of close observa- 
tion bring the subject to a determined point. The author (and 
translator) will be glad of any such communications. 

Although the number of these cases, as yet examined, is not 
very great, still it is indicative enough, since the subjects 
were taken at chance and scattered through a considerable 
period of time. 

Now, gentlemen, what shall we conclude from the develop- 
ment of these certainly unlooked for facts ? Can we believe 
that we are here dealing with a normal and physiological, and 
not a pathological condition ? We must consider these ap- 
pearances as morbid, since they do not always appear ; but 
only 13 out of 46 examined were free from them. 

The experience of physicians, however, has not shown that 
purulent inflammations of the ear appear so often. 

May it be true, that such an otitis interna as our anatomical 
examinations have shown is only anatomical or normal, and 
never, showing itself, by any disturbing symptoms, during life ? 

As I have already said, 1 am not able to give a positive an- 
swer to this question. Is it probable, however, that changes in 
structure, similar to those which in adults give rise to evident 
symptoms, and which affect, not only the part involved, but 
the whole organism ; is it probable, I ask, if these changes pro- 
duce no results, when occurring in children % In general, we 
know that the nervous system of a child reacts even as strongly 
as that of an adult to any disturbing cause. 

As long as we have no positive evidence, should we not as- 
sume that these cases have not been properly estimated, or pro- 
perly observed ? 

I have been obliged, in almost every section of aural surgery 
which we have studied together, to show you more or less ini- 



PURULENT CATARRH IN CHILDREN. 171 

portant facts, which have either not been esteemed enough, or 
have been improperly estimated, or as facts which have escaped 
the observation of practitioners and aural surgeons. I will 
only now recall one instance to your mind. How far, hitherto, 
have physicians known that a sluggish intellect, dullness in the 
head, and troublesome attacks of vertigo, have had anything 
to do with a diseased condition of the ear ? To the aural sur- 
geon, the daily occurrence of such cases proves the co-existence 
of symptoms and condition. Notwithstanding this, the most 
cultivated clinical physicians seem to have no idea of this, and 
you will not find in the writings of German aural surgeons any 
thing to indicate that these things may be observed. 

Nowhere dare we leave less to authority, nowhere can we 
rely so little on previous researches, and nowhere can consi- 
derate and assiduous observations of clinical and anatomical 
facts find so much that is new and unexpected, as here in the 
pathology of aural surgery. The previous laborers have left 
much to be done. How insufficient and wanting have been 
the observations hitherto made on the living ? I have been 
already obliged to show you observations on the dead body 
in some directions are entirely wanting, in others are incom- 
plete. 

If, for instance, in the examination of the infant cadaver, 
attention had been turned to the temporal bone, the striking 
appearances then seen would have certainly arrested the atten- 
tion of the physician. The examination has been neglected ; 
the facts have, consequently, not been shown, and now-a-days 
it is only exceptionally that a physician who can give no point 
of origin for the pain, thinks of the ear, and of the possibility 
of an inflammation there, until a purulent discharge shows 
itself. 

If we examine more closely the literature of the subject, 
we find that in various times, observing and careful men have 
plainly shown that perforation of the membrana tympani, 
and the otorrhoea following it, were only results of otitis inter- 
na, and that this must always precede the otorrhoea, and that 
we attempt to recognize the affection earlier, in order to guard 
against the purulent discharge, and cause the whole process to 
run a mild course. In 1825, Dr. Schwartz, a physician in 
Fulda, said, that " inflammations of the ear are very often over- 



172 PURULENT CATARRH IN CHILDREN. 

looked, occurring in children not old enough to speak," and he 
called attention to the symptoms by which it might be distin- 
guished from other affections, especially from inflammation of 
the brain and its membranes.* Frederich Lud. Meissner, in 
his Text-Book of the Diseases of Children, says, that " aural 
inflammation is of that kind most commonly overlooked in 
childhood, because children are not able to indicate the situa- 
tion, kind, and degree of the pain." It is most commonly 
confounded with diseases of the brain. 

According to Helfft (1847), " the symptoms of otitis interna in 
children are very similar to true meningitis.f We must always 
look to the head as the point of origin of loud and intermittent 
cries of pain, when the chest and abdomen have been found 
in a normal condition. The absence of vomiting and consti- 
pation, as well as the slight febrile reaction, is evidence that 
there is no considerable inflammation in the brain." 

These various warnings seem to have been little regarded ; 
and since they were given, we seem to have gone backward ; 
for you will find no attention paid to the subject in our present 
text-books. In the well-known works of Rilliet and Barthez 
(1853), and in those of Bouchut (1852), I can find nothing 
pertaining to the subject, and quite as little in other text-books 
on the diseases of children, even in those which have appeared 
since 1858, in which year I made my first communication, 
concerning this peculiar post-mortem appearance in small 
children, to the Medical Society of this city. 

But, gentlemen, not only anatomical facts, but also daily 
practical experience proves to us the uncommon frequency 
of diseases of the ear in children. Earaches are such com- 
mon occurrences in children who are old enough to give 
the seat of pain, that there is scarcely a child that has not 
suffered at one time or another with them. Examination shows 
that this earache generally depends upon inflammation of the 
external or middle ear, and that it is seldom of a nervous neu- 
ralgic character. Of the otorrhoea that comes under our care, 
the greater part, certainly more than half, had its origin in 

* See SeiboWs Journal fur GeburtshiJfe, B. 5, Hft. 1. Again presented in the third 
part of Linkers Sammlung auserlesener Abhandlungen und Beobachtungen aus dem 
Gebiete der Ohreriheilkunde. 

\ Journal fur Kinderkrankheiten, Schmidt's Year-Book. 1848. B. 58, p. 337. 



PURULENT CATARRH IN CHILDREN. 173 

childhood or infancy. Hardness of hearing, of different grades, 
will often be found in children when a test examination 
is made. 

If, then, it is a generally acknowledged experience, that 
inflammatory diseases of the ear are quite common in children 
of advanced age, it is probable that they occur quite as often 
in the very first periods of childhood ; but we are not so well 
assured as to this, because of the difficulty of recognizing the 
affection in infants, where there is no purulent discharge. The 
anatomy of the parts, and the history of their development, 
show us facts which prove how favorable circumstances are 
in infancy to disturbances of nutrition in the cavity of the 
tympanum. 

I must call to your attention that process of dura mater, so 
rich in vessels, which in childhood extends, by means of the 
fissura petroso-squamosa, to the cavity of the tympanum and 
mastoid cells, and through which the dura mater and the 
mucous membrane of the middle ear come into closer relations 
in respect to nutrition than is the case with adults. Each 
disturbance of nutrition and circulation in the membranes of 
the brain, which are quite common to children, must extend to 
the middle, from the fact that the blood supply of both is con- 
veyed in the same channel; and the reverse is also true, — 
every primary affection of the ear in a child is apt to produce 
symptoms of cerebral disturbance. 

I must not omit to state here that all the children whom I 
examined, who were afflicted with otitis interna, and when I 
was allowed to make a full examination, showed also conges- 
tion and hyperemia of the brain. 

I have still further to describe to you the condition in which 
we find the cavity of the tympanum in the foetus and the newly 
born child. As I have shown,* this does not contain the fluid 
of the amnios or mucous secretion, as has been previously gene- 
rally believed, but is filled up with a cushion-like swelling of 
the mucous membrane of the wall of the labyrinth, which 
reaches up to the internal surface of the membrana tympani. 
The respiratory process soon diminishes this mucous growth, 
partly by shrinking, partly by degeneration of the structure, 

* Wurzburg Yerhandlungen. B. 9, case 18. 



174 PURULENT CATARRH IN CHILDREN. 

and it gives place to air. According to several examinations 
of children who died during parturition, or not long after, 
the diminution in size of this mucous pillow was commenced 
before birth, and in such cases we find strikingly many epi- 
thelial cells filled with fat in the cavity of the tympanum. 

"We know, that in the first period of life, a developing 
process is going on in the middle ear. Our daily practical 
experience teaches us, that pathological changes, interfering 
with the nutritive processes, are more easily produced in parts 
which are increasing in power, and where metamorphosis and 
evolutions are going on. As an example of the truth of this, 
I call to your mind how often diseases of the female sexual 
system originate during the time of development, during each 
menstrual period, and especially during the puerperal process. 
If we add to these facts, that nasal and pharyngeal catarrh, 
which so often give origin to the catarrh of the ear, are the 
every-day experience of children, you will be less surprised 
at the uncommon frequency of otitis in the young subject, and 
it will be a question whether we are able to recognize the affec- 
tion during life. 

You comprehend, gentlemen, the difficulty of a diagnosis of 
an affection of the ear, unaccompanied by a discharge in young 
children, who are not able to designate any situation of their 
pain, and when it is impossible to make any sufficient exami- 
nation of the part, or determine the degree of hearing. You 
see how we want fixed points of which to seize hold, such as 
we have in adults, in order to distinguish an inflammatory 
affection of the ear. Yet, you must not allow this state of 
things to deter you from your duty. We are very often ob- 
liged in internal diseases, especially in the practice among 
children, to keep ourselves with very few positive conclusions, 
and we must work by exclusion greater or lesser probabilities, 
and also look at the result of our therapeutics, to aid us in 
forming a diagnosis. We are not in a narrower limit for a 
diagnosis than in many other cases. The principal difficulty 
lies here : — the physician, who approaches the bed of the sick 
child, scarcely counts the various possibilities which go to 
clear up the affection. If we but once understand that affec- 
tions of the ear belong to the common ones of children, and 
compare the symptoms with which these affections declare 



PURULENT CATARRH IN" CHILDREN. 175 

themselves in grown persons with the peculiar ones of the in- 
fant organism, we will certainly be able, by exclusion of the 
other organs, to make our circle narrower and narrower, until 
finally, with more and more certainty, we have fixed upon the 
ear as the origin of the trouble. 

Our conclusion will also be assisted by a previous expe- 
rience. 

Allow me, then, to enter into a further detail of the symp- 
toms by which otitis interna in young children will declare 
itself. I must assume, however, that a diagnosis from analogy 
is allowable, since in the peculiar circumstances clinical proofs 
are wanting. Parents, who bring their children with otorrhcea 
to the physician, will often give considerable information as to 
the condition of the patient the day before the discharge began. 
When the collection of pus is at all considerable, the symp- 
toms of irritation can scarcely be wanting, and the affection 
will declare itself in the morning, the child crying as if in 
severe pain. 

Some physicians ascribe a peculiar character to the cry of 
children in otitis ; whether this be true or not, we will leave 
undecided. Certainly the cry of pain which arises from pain in 
the ear, even when coming from strong men, is described as 
one of the most terrible, it being extremely severe and pene- 
trating. This pain sometimes lasts whole hours, often days, 
without very long intervals, and is subject to severe exacerba- 
tions, especially during the night. 

It can thus be distinguished from affections of the lungs, 
pleura and trachea, since in these diseases children can never 
cry loudly for any continued length of time. The cry from ear- 
ache would most resemble that from inflammation of the bowels 
or brain, but the failure of the remaining symptoms of these 
diseases will allow us to distinguish them. 

It will be important to note the circumstances under which 
the symptoms are decreased or increased. * 

In affections of the middle ear the pain would be increased 
in every shaking of the body, and every change in the posi- 
tion of the head, by every effort of swallowing, mostly in suck- 
ling, the child flinging itself away from the breast, or from 
the bottle at the first attempt, while its usual nourishment ad- 
ministered by means of a spoon will be more easily taken. 



176 PURULENT CATARRH IN CHILDREN. 

Cold, noise will increase the symptoms of pain, while perfect 
quiet, warmth, especially moist warmth, as pouring warm water 
into the canal, cataplasms over the ear, will quiet the pain. 
Nasal catarrh will be a common complication — cold in the head. 
You will find it very difficult to come to any conclusion as to the 
degree of deafness, or loss of hearing, which is connected with 
the accumulation of purulent matter in the middle ear. It is 
true, that even in the most tender age we can come to an 
unequivocal result, as to whether the child hears a loud noise 
or not, but who can tell whether a child does not respond to 
sounds in consequence of a morbid process connected with 
depression of the sensorium, or from want of power in his 
auditory apparatus in conducting the sound. When we 
remember the facts, often alluded to, of the relation of the ves- 
sels of the dura mater and the mucous membrane of the mid- 
dle ear in the child, and the tendency of extension of diseases 
of the ear to the brain in the adult, we will not be surprised, 
considering the very impressible brain and spinal cord of the 
child, if the meningeal and cerebral symptoms are here much 
severer than in adults. 

It is undoubtedly true, that a permanent deafness, or convul- 
sions of the limbs, or spasms of the muscles, may be excited by 
an otitis interna. 

The fact may have struck you that in the post-mortem exa- 
minations, whose results are now under consideration, the mem- 
bran a tympani was never perforated, and took very little part, 
comparatively, in the morbid process. This fact is due to the 
width of trie Eustachian tube in infancy. It is not only rela- 
tively, but absolutely wider than in adults, measuring in its nar- 
rowest part about a line and a half. Therefore, a complete 
closure of the cavity of the tympanum, and a consequent mass- 
ing of secretion in it, with the well-known results, is not so liable 
to occur.. These normal conditions allow us to say, that in the 
otitis of children there is much less danger to the membrana 
tympani of children than of adults, and that the prognosis is 
on the whole better, and perhaps the disease may run its course 
without any decided pain. 

What shall be the therapeutics for an otitis interna thus 
diagnosticated as occurring in an infant ? In the case of a strong, 
well developed child, Ave can apply one or two leeches behind 



PURULENT CATARRH IN CHILDREN. 177 

the ear to relieve the pain and hyperemia. I would not gene- 
rally apply poultices to the ear, since they will certainly excite 
a profuse otorrhoea, and the frequent filling the ear with warm 
water will probably subdue the pain quite as effectually. 

Injections of cold or lukewarm water from the nose will 
have a good effect in removing mucus from the nasal cavities 
and upper pharyngeal space, and are especially to be recom- 
mended when there is a severe cold in the head, which is a 
frequent accompaniment of the otitis, and serves as an assist- 
ant in the diagnosis. In this place I would like to speak of an 
old woman's remedy for cold in the head — that is, the insertion 
of an oiled pointed pigeon's feather through the nose into the 
mouth ; this to be done at somewhat frequent intervals, excit- 
ing sneezing, and assisting materially in clearing out the parts. 
Since there is a very slight amount of danger to the membrana 
tympani, and on account of the ease with which the secretions 
of the cavity of the tympanum are removed, an emetic will 
hardly be needed. As to the introduction of the catheter, I 
should not answer Yes or ~No. (I should answer ISTo most decid- 
edly. Practitioners will readily comprehend the almost impossi- 
bility of performing such an operation on a young child, and Dr. 
T.'s own facts as to the width of the pharyngeal entrance to the 
tube demonstrate its uselessness. Why the Continental sur- 
geons have such a desire to introduce the catheter in every 
affection is as equally unintelligible as the aversion of British 
and American surgeons to ever using it.) 

I hope, gentlemen, that in your future practice you will fol- 
low out this subject, and when you can ascribe no sufficient 
reason for the crying of a child, and for its deaf and convulsive 
condition, that you will remember the frequent recurrence of 
this pathological picture, which we have seen in these sections. 

There is a prevailing custom among many physicians, to 
ascribe many of the troubles of the first period of life to the 
cutting of the teeth. 

We cannot deny, that this view has historic right, as well 
as the vox populi, on its side, and that it is extremely con- 
venient. 

It does not appear to me, however, as proven, that a physio- 
logical process for which preparations have been made, and 
which goes on with so few local and sudden changes, should 

12 



178 PURULENT CATARRH IN CHILDREN. 

constantly lead to constitutional disturbances of the system. 
Let it be as it may, I do not intend to mix myself with the 
vexed question; so much is uncertain, that in the practice with 
Dentitio difficilis, abominable malpractice is often seen, exact 
examination omitted, for the above convenient subterfuge, and 
much more important local disturbances overlooked. Among 
the last we may place otitis, which has just been described. 



LECTURE XIX. 



Its Subjective and Objective Symptoms. — Treatment. — Perforation 
of the Membrana Tympani; its Importance. — The Artificial 
Membrana Tympani. 

Gentlemen — We will speak to-day of the chronic internal 
otitis. This is much more common than the acute. It is 
either developed itself from this latter, or arises from the ex- 
tension of an otitis externa or myringitis upon the cavity of the 
tympanum. It seems most often to result from a neglected 
otorrhoea of the external ear. We cannot believe in a long 
continued suppurative inflammation of the middle ear, which 
does not lead to perforation or impairment of the integrity of 
the membrana tympani. The pus will naturally run from its 
internal situation, outwards, and we may call this form otor- 
rhoea interna, to distinguish it from that occurring from the 
external auditory canal. 

In the greater number of cases, the beginning of chronic 
otitis interna may be traced back to the earliest period of 
childhood. The symptoms are mostly limited to hardness ot 
hearing and a purulent discharge from the ear, both of various 
grades of intensity. Pain is only felt after some distinct 
causes have been at work — injury to the part during an ulcer- 
ative process, in the sub-acute stages, caries, etc. In the last 
named case, the pain is severe and long continued. 

If we syringe the ear, we can observe two kinds of secretion. 
The purulent, which is equally mingled with the waters inject- 
ed, and colors it yellow, and a mucous secretion which is not 
dissolved in the water, and which floats around the vessel in 
long and jagged masses. Sometimes there is more pus than 
mucus, and vice versa. There will also be little lumps, which 
consist of the dried epidermis of the external canal. 



180 CHRONIC PURULENT CATARRH. 

On examination of the lower portion of the auditory canal, 
we find it superficially softened and loosened. Often the bony 
portion of the canal is narrowed above, and latterly we see it 
discolored with scabs and crusts, consisting of dried and thick- 
ened scales of epidermis, which can only be slowly removed. 
These prevent a full view of the background, and their re- 
moval often, almost immediately, improves the hearing. The 
membrana tympani, as far as it exists, seems thickened in 
all its surface, often partly calcified, superficially, somewhat 
covered with secretion, more or less infiltrated and dense. The 
edges of the perforation are to a greater or less extent reddened. 
These perforations have been incorrectly described as of a round 
shape, and with a sharp border; they resemble kidney, with 
the hilus towards the end of the malleus, when the perforation 
occurs in the centre of the membrane. The handle of the mal- 
leus, at its lower extremity, is sometimes involved and lies in 
the middle of the perforation. If the membrana tympani be 
for the greater part wanting, then the uppermost portion of the 
handle of the malleus is only to be seen. This, with the pro- 
cessus brevis mallei, as well as the outer border of the mem- 
brana tympani, is generally, almost always, remaining, although 
it is often hard to recognise and distinguish from the neighbor- 
ing swollen tissue. In all the cases, where the structure of the 
membrana tympani is perforated about the deepest portion of 
its concavity (called Umbo by Troltsch and Hyrtl), the lower 
portion of the handle of the malleus, which is now deprived of its 
hold on the membrane, lies deeper in the cavity of the tympanum. 

In some cases, the mucous membrane of the cavity of the 
tympanum is extremely little swollen and hyperasmic, while in 
others it is so to a high degree. It is generally covered at the 
lower part with secretion, which can be pushed outward 
through the Eustachian tube, with a slight sizzing sound. In 
cases where the whole cavity is filled with pus, and the hole in 
the membrana tympani is a small one, the patient can press the 
secretion through the perforation, drop by drop, without the 
slightest sound. At the moment when the patient stops the 
pressure, the drop, which was at the time passing through the 
perforation, will fall back into the cavity of the tympanum 
Occasionally the edge of the perforation, even when it has no 
drop of fluid, pulsates with the motion of the heart. This is 



CHRONIC PURULENT CATARRH. l8l 

regularly the case when there is any pus or fluid on the inner 
surface of the perforation ; and then the pulsation is doubly dis- 
tinct, on account of the strong and glancing light of the drop. 

As a consequence of this deficiency in the membrana tym- 
pani, that part of the wall of the labyrinth — the promontory, 
lying opposite the lower and anterior portion of the membrana 
tympani — can be distinctly seen, even when the mucous mem- 
brane of other parts is not swollen, with vessels running over 
it. We can often, also, distinguish the anterior edge of the en- 
trance to the fenestra rotunda. The membrane of the fenestra, 
in consequence of the oblique position of the niche on whose 
border it is first attached, you will not be able to distinguish, 
even if the whole of the membrana tympani be gone. The 
long process of the incus more often entirely fails to be 
seen. If it be wanting, the connection between the stapes 
and the other bones composing the chain is of course broken. 
We are occasionally, also, able to distinguish the little head of 
the stapes — generally situated on the most posterior and upper 
edge of the visible wall of the labyrinth — as a little elevation 
covered with reddened mucous membrane. Finally, a more 
common condition, both on the living and dead subject, 
is a union of the edges of the perforation with the ossicula aa- 
ditus, or with the promontory.* 

The degree of hearing remaining in the above described con- 
ditions is very various, reaching from total deafness to enough 
understanding of what is said to suffice for ordinary vocations. 
It depends greatly upon the amount of secretion and swelling. 
It is well known to you that a perforation of the membrana 
tympani by no means necessitates or involves a high degree of 
hardness of hearing, although you will often find an opposite 
view taken, not only among the laity, but also in the profes- 
sion. Commonly the hearing, in consequence of the perfora- 
tion of the membrana tympani, is so affected that a watch which 
may be heard for six feet in normal hearing, can only be heard 
from one to two ; but this leaves sufficient hearing for ordinary 
purposes. I know several persons with perforation of the 
membrana tympani on both 6ides, and yet so little disturbed 
by it, that they do not pass at all for deaf persons, or as hard of 

* Vide Virchow's Archives, B. 21, 3d Hft. 



182 CHRONIC PURULENT CATARRH. 

hearing. Even a complete loss of the membrana tympani does 
not entirely destroy the hearing, although it suffers severely 
therefrom. Patients generally hear better with a perforation 
of medium size, than with a very small one ; but every per- 
foration of the membrana tympani must be regarded as of mo- 
ment, and has the following importance : that is, that thereby 
the mucous membrane of the cavity of the tympanum has lost 
its natural protection, and is open- to atmospheric influences, and 
will be retained in an irritated condition, which may increase 
to an acute affection of more importance. The perforation is 
generally the reason that a chronic otitis, with otorrhcea, often 
remains permanent — a radical cure not being possible. 

Such forms of disease often run a course of years, without 
any further consequence than that the patient has a discharge 
from the ear, and is somewhat hard of hearing ;. and this con- 
dition does not receive the amount of attention which it de- 
mands, especially if it be but on one side. The discharge va- 
ries at different times in degree and kind, and sometimes dis- 
appears altogether for a time. The surgeon is generally first 
called to see such a case w T hen, after a cold or injury, an acute 
and painful condition is present. If we except those cases 
where important complications (such as ulceration of the bones) 
have occurred, the pain and other symptoms in such a sub- 
acute otitis interna are less than in a primary otitis ; because, in 
consequence of the perforation in the membrana tympani, there 
is seldom any great amount of secretion in the cavity of the 
tympanum — it being able to pass out, if the opening be not ac- 
cidentally closed by a mass of epidermis. If neglected and left 
to itself, chronic otitis interna may lead to the formation of 
polypi, to caries, and to various disturbances, of whose great 
importance for the life of the patient we will speak more fully. 

We are often able, by proper and long-continued treatment, 
to bring such a process to a stand-still — to lessen the purulent 
discharge and hypersemic swelling of the part ; and we often, 
also, obtain with this a considerable improvement in the hearing. 

The treatment must be directed to the end of reducing the 
hypersemic swelling of the mucous membrane of the cavitas 
tympani, and to render its secretion normal. 

Diligent and thorough removal of the secretion is- especially 
important. 



CHRONIC PURULENT CATARRH. 183 

The necessary injections with luke-warm water must be made 
very carefully, since a heavy stream from a large syringe can 
easily do great damage, in the sensitive and loosened condition 
of the parts. Sometimes, when the greatest precautions are 
taken, vertigo and fainting fits result from these injections. It 
is well to fill the ear with warm water some time before the in- 
jection, so that the secretions may be made as loose as possible, 
and a small stream be sufficient to remove them. In some 
cases, the end of cleaning the ear is better attained by the use 
of a small camel's-hair brush. 

A thorough removal of the secretion is very difficult, when 
the opening into the cavity of the tympanum is small and we 
can only inject a small quantity of water. 

The patient, in such cases, should endeavor to pass in air 
through the Eustachian tube, so as to drive the secretion for- 
ward, where it will be more accessible. In such cases the 
dropping in of astringents is of comparatively little use, while 
in other cases, by constant and diligent perseverance with 
them, we may be able to bring the mucous membrane again 
into a healthy condition. It is highly beneficial to often press 
air into the middle ear by means of the catheter, because in this 
way we can most thoroughly remove the secretion, and keep 
the canal open. I have no good result from the use of the 
vapor of ammonia, but I have seen great benefit from the vapor 
of warm water. We must never, in these cases, lose sight of 
the condition of the mucous membrane of the pharynx. Fre- 
quent gargling is of great service, for by this means we increase 
the power of the canal, and favor the discharge of the secretion. 

The constitutional treatment must never be neglected — espe- 
cially the use of properly-adapted mineral waters ; change of 
air, residence in a warm climate, often having a beneficial 
effect on a diseased mucous membrance. (Great attention 
should be paid to the diet of the patient, especially when this 
affection occurs, as it does in the large majority of cases, in the 
half-nourished children of our poorer classes in New York. 
The physician will find the patients living on slops and poorly- 
nourishing vegetables, such as cabbage, and a change to bread 
and milk, fresh meat and eggs, etc., will work wonders. Let us 
never let local symptoms shut out our view of the constitu- 
tional cau.se, which proceeds all the trouble.) 



lS-i CHRONIC PURULENT CATARRH. 

It has occurred in my practice, that patients with such a 
chronic blennorrhea of the cavity of the tympanum, whom I 
had treated for a long time with very little result, have re- 
turned from a trip to Madeira nearly cured, or in such 
a condition that proper local treatment had soon a good result. 

The local treatment must be continued for a long time, even 
when there is no more evident discharge — at most, only a 
slight one, whose seat is very deep. We should only observe 
the precaution to allow a considerable interval to elapse be- 
tween the syringing and the dropping in of astringents. 

Under favorable circumstances, we are often able, by these 
simple means, to bring the process to a full stop, and to close 
the opening in the membrana tympani. 

To those who doubt that perforations of the membrana tym- 
pani will heal, I would like to adduce cases in my own experi- 
ence, among which are those of two members of our profession. 
Some cases occurred to me, when 1 was obliged to refer back 
to the history of the case, in order to see in what part of the 
membrane there was previously a perforation, so little trace of 
it remained. I once examined such a healed perforation on the 
dead body.** In this case the microscope revealed that there 
had been a loss of substance, and that a spot a little thinner 
than the remaining portion of the membrane was a cicatrix. 
In practice, we may quite often see such cases on the living. 
The cicatrices are generally seen as thin, sharp-bordered, su- 
perficially sunken-in spots, which sometimes have a peculiar, dif- 
fuse, mother-of-pearl-like reflection, and which, on blowing in 
upon the membrana tympani, stretch out in their full dimensions. 

If a perforation should close, the patient will likely not hear 
so well immediately after ; but we must not attempt to prevent 
the closure. If we open a freshly-healed perforation, the pa- 
tient will hear better for the moment ; but, on the other hand, 
if we leave the cicatrix alone until it becomes firm, the hear- 
ing will either gradually improve of itself, or from the intro- 
duction of warm air. This must not be attempted for some 
time after the healing, and then must be done with the greatest 
care, lest an otorrhoea be excited. The closure of the per- 
forated membrana is the most desirable and permanent means 

* See Virchovfs Archives, voL 17, p. 16. 



CHRONIC PURULENT CATARRH. 185 

of improvement, and our treatment should be directed to secur- 
ing this end. 

We must avoid, however, lessening the size of the opening 
until we have bettered the condition of the cavity of the tym- 
panum, and the mucous surface of the membrane, or we shall 
not have improved the state of things, but, on the contrary, 
have made it worse, because, by so doing, we shall have rendered 
the way out of the pus more difficult. 

We must always remember that we are dealing here with a 
fistulous opening, which will heal with very little aid, so soon 
as the morbid condition of the fistulous canal is removed; but 
that we will render the condition of things worse if we close 
the opening without healing the canal, because the accumulation 
of a mass of pus, with all its consequences, is thereby induced- 
We can best attain the desired end of healing the fistulous 
canal by means of appropriate treatment, as given above, and 
we can aid the growth of new substance by a careful, well- 
watched irritation of the edges of the perforation. 

Many authors speak of very favorable results from such a 
treatment alone, i.e. touching the edges with solutions of 
nitrate of silver, etc. Even in old cases, and where consider- 
able loss of substance has occurred, so far as I have practised 
this treatment, I cannot especially recommend it. In one case 
I made the opening larger instead of smaller, although I 
exercised the greatest care. 

I should only like to use this treatment when the opening is 
very small, and the patient could remain under constant obser- 
vation. It is certainly a rational treatment in theory, for we 
occasionally see a lessening of the opening begin after an acci- 
dental inflammation of the part. 

In order to diminish the evil results occurring from perfora- 
tion of the membrana tympani, it has been often attempted to 
insert an artificial membrane, and thus close the opening. 
The first recorded experiment of the kind was made by Auten- 
reith in Tubingen, who, in 1S15, advised the placing of a short 
elliptical leaden tube in the ear, over the end of which a piece 
of the bladder of a small fish was placed, drawn over while wet, 
and after drying varnished. How far this experiment succeeded, 
I am unable to say. In later times, Toynbee, of London, in 
1853, recommended an artificial membrana tympani, consisting 



L86 CHRONIC TURULENT CATARRH. 

of a thin plate of vulcanized india-rubber, in the centre of which a 
fine silver wire, about an inch long, is fastened, which has a ring 
on its outer end, by means of which the instrument can 
be easily removed. Such an artificial membrane is 
pressed against the remains of the natural one, and 
sometimes causes a truly magical effect.* I have seen 
cases where conversation could not be heard unless 
the voice were elevated in close proximity to the ear, 
so much improved, that some steps off each softly- 
spoken word could be repeated by the patient. In 
cases where the perforation is very small and very 
Fi „ 9 much of the membrane remains, the artificial mem- 
brane often causes too much irritation, and its use 
cannot be continued when there is any evidence of recent in- 
flammatory action. We can never tell beforehand whether the 
instrument will do any good or not, and we must seek by 
repeated attempts to find the place where it improves the hear- 
ing the most. 

In what manner the often striking benefit from the use of 
the artificial membrana tympani occurs, we cannot exactly say. 
It seems to me that there are various ways in which it may 
do good. It is certainly seldom beneficial from the mere 
closure of the cavity of the tympanum, which Toynbee gives as 
its mode of effect. It often improves the hearing when its 
edges are so folded and everted that there is no perfect closure 
of the cavity, and it sometimes causes no change in the hear- 
ing power if a portion of it be cut off. In all cases the 
improved condition of the hearing is accompanied by the 
advantage that the mucous membrane is guarded from 
the effects of the atmosphere, and I often use the gutta percha 
only for this purpose. In this case the silver wire can be 
shorter, for it is not necessary that it should be introduced so 
far as to rest upon the remains of the membrana tympani. 
That the improvement in hearing by the use of Toynbee's instru- 
ment did not depend on the closure of the cavity, I was 
able to prove by the use of collodion, which closed the cavity 
without benefit to the hearing, which was immediately benefit- 
ed by the disk of gutta percha being introduced, or any other 

* Vide Diseases of the Ear, by Toynbee, Philadelphia e<L, p. 191, et seq. 



CHRONIC PURULENT CATARRH. 187 

firm body. In the most cases it seems to be the pressure on 
the membrana tympani, and on the handle of the malleus, 
which causes this sudden and wonderful improvement. This 
opinion is sustained by the fact that the same effects are pro- 
duced which are obtained by the introduction of Toynbee's in- 
strument by the use of a little ball of moist cotton, which is 
pressed on a certain part of the drum. Yearsley, of London, 
in 1848, first recommended this procedure, and it is to be pre- 
ferred to the gutta percha where the latter proves irritating, or 
a considerable purulent discharge is present. By the use of 
an astringent with the cotton this may often be diminished. 
Many patients are able, after a few attempts, to place the cotton 
on the right point. In patients who are less intelligent, the 
plate of gutta percha is to be preferred, because it is easier to 
introduce, and when it is misplaced it is easy to bring again 
into its proper position. Frequent cleanings of the ear by 
means of injections are the more indicated y because the use of 
the instrument tends to increase the secretion and irritation. 
Yet, when care is taken, the irritation caused is very slight. I 
have occasion, from time to time, to hear of patients who have 
worn this instrument for years, and always with undoubted 
benefit. The instrument must now and then be replaced by a 
new one, since, after the use of months, it is unfit for its purpose. 
We can imagine the changes which would be likely to occur 
from the pressure of this foreign body on the membrana tym- 
pani and the handle of the malleus, and which, according to 
my view, generally is the cause of the improvement in hearing. 
We remember that in a purulent inflammatory process there 
is a solution of the continuity of the ossicula auditus. This 
occurs most commonly in the articulation of the incus and stapes, 
whether it be by simple loosening of the soft capsule of the 
joint or by means of a loss of the long process of the incus, 
which, as we have seen, is sometimes destroyed by caries. 
When the membrana tympani, with the incus, is pressed against 
the stapes, the continuity will be restored. Erhard. of Berlin, 
author of the Bationnelle Otiatrik (a queer book), claims to have 
been the first to have found the method of curing deafness by 
pressure on the membrana tympani on his own ear, and to have 
published it in '49, without knowing of Yearsley. (I saw in 
one of Dr. Erhard's cases, at his office in Berlin, a most remark- 



CIIRONIC PURULENT CATARRH. 

able instance of improvement in hearing by the placing in of 
cotton. In this case the patient, a boy of about 14, had learned 
to place it in itself. I was unable to adjust it as well or as 
quickly as he could do. Recently I saw a case of like character, 
though not so marked, in the improvement shown, under the 
care ot^ Dr. Noyes in the New York Eye Infirmary.) 

These changes, affecting the little bones of hearing, which 
would seem to be so seldom, are not as rare as we would natu- 
rally think. In Toynbee's catalogue of preparations of the ear, 
among the great number of sections which he has made, the 
entire loss of the incus occurs four times. Its long process was 
wanting ten times, partially or fully, and fifteen times the arti- 
culation between incus and stapes was lost. I myself found the 
last state of things three times on the dead body. In one case 
I was not able to get out the bones till eight days after death, 
and the changes which occurred may have been only macera- 
tive, the cavity of the tympanum being filled with pus. The 
other cases cannot thus be explained, for on opening the cavity 
there was no trace of injury. Such a separation of the delicate 
connection between incus and stapes can occur during life by 
means of a severe concussion of the head, and especially by 
means of a sudden change in the pressure of the air in the middle 
ear, similar to the manner in which a laceration of the membrana 
tympani may occur. Recall to your mind only what we 
observed in this respect in our observation of the physiolo- 
gical importance of the mastoid cells. Collections of purulent 
exudation can produce such a result by ulceration, and the 
whole chain of bones may pass out. Further, a gradual or 
sudden tearing of the delicate membrane may occur by means 
of a strong expiratory effort, when a spurious anchylosis, by 
means of adhesive bands, has rendered the parts inflexible. 
The last named condition obtained in my ten cases, and in a 
number of those of Toynbee. 

As the separation between incus and stapes by no means 
occurs only with purulent deposits in the cavity of the tympa- 
num and perforation of the membrana tympani, so the im- 
provement in hearing by pressure on the membrana tympani 
may occur in persons where this is entirely uninjured. I have 
seen one such case, where the introduction of a little wad of 
cotton improved the hearing for one day in a remarkable man- 



CHRONIC PURULENT CATARRH. 189 

ner, and in the recent and ancient literature, you may find 
numbers of cases related, where patients hard of hearing have 
accidentally found, that by introduction of a foreign body in 
the ear they could temporarily improve the hearing. As such 
assistances to hearing all possible things have been used : — 
pencils, paper, shavings, onion bulbs, lint, etc. One of the 
most interesting of these cases is related by Meniere^ a dis- 
tinguished and excellent Aural Surgeon.* 

An old judge had been accustomed for at least 16 years, by 
pressure of a blunt, gold needle against the membrana tym- 
pani, to make for himself, for an hour or so, a tolerably good 
hearing-power. Meniere examined the ear during this state 
of things, found the membrana tympani uninjured, and that the 
pressure was made upon the handle of the malleus, which was 
pressed somewhat inward. He speaks of having seen several 
similar cases, and considers them cases of nervous deafness, 
which were improved to a certain degree by pressure upon the 
ossicula auditus, and through them on the labyrinth. 

* Traite des Maladies d'Oreille, par Kramer, traduit par Meniere. Paris, 1848, 
p. 526. 



LECTUEE XX 

AURAL POLYPI. A FULL CONSIDERATION OF THE IMPORTANCE OF 

DISCHARGES FROM THE EAR. 

Origin and Structure of Aural Polypi. — Treatment. — Otorrhoea, 
considered with reference to its Influence on. the Circulatory 
System. — Emboli. — Septic Infection. — Metastasis. — Caries of the 
Temporal Pone, with its Consequences. — Phlebitis. — Abscess of 
the Brain. — Meningitis Purulenta. 

Gentlemen — I have already alluded to aural polypi as among 
the consequences of otorrhoea. We will to-day undertake a 
short description of these morbid growths. 

Aural polypi may be described as swellings, rich in blood, 
and consequently bright red in color, of somewhat round 
shape, sometimes of a soft consistency, and bleeding on being 
touched ; sometimes dense in structure, and with a shining sur- 
face, generally grape-shaped, or lobulated, and sometimes hav- 
ing a large base, and sometimes a small one, — pedunculated. 
They vary greatly as to size, sometimes filling up the whole 
auditory canal, extending out of the meatus like a fungus or 
mushroom. Sometimes they are found covered with pus and 
secretion lying in the deepest part of the ear, and scarcely so 
large as a pea. If lying deeply, they are redder and softer, and 
resemble a strawberry, since its round superficies is covered 
over with minute elevations. If it extends out of the meatus, it 
will be covered with a thick integument, which does not secrete, 
so that at first sight we are apt to think it a part of the auricle, 
or that it is a button-shaped tumor, which has formed upon it. 

Aural polypi take their origin from all parts of the auditory 
apparatus. According to my experience, they rarely arise from 
the^ external auditory canal. Toynbee and Wilde have found 
their most common origin to be from the canal, and the last 
named on the posterior wall, but they extend very often from 



AURAL POLYPI. 191 

the membrana tympani upon the canal, and we may sometimes 
see numbers, with independent roots, attached around about this 
region. If they arise from the superficial surface of the mem- 
brane, it is generally from the posterior and upper portion of 
this membrane near its edge. 

I once found, on the dead body, in connection with a polypus 
of the external auditory canaL, and of the Eustachian tube, 
what in accordance with its position and microscopic struc- 
ture proved to be a polypose, degenerated membrana tympani. 

I have also, on the living subject, met with excrescences, the 
form and extraordinary sensitiveness of which led me to regard 
as enlargements of the membrana tympani. 

Aural polypi arise most commonly from the mucous mem* 
brane of the cavity of the tympanum, and from the upper por- 
tion of the Eustachian tube. Very often growths, which half 
fill the auditory canal, have their origin just behind the mem- 
brana tympani, even partly in the mucous surface of the mem- 
brane itself. I have some preparations showing this. If polypi 
extend out into the auditory passage, through a hole in the 
membrana tympani, they make almost the same impression as if 
their origin was in the membrana tympani itself, and mistakes 
as to what point they actually arise from may often occur. 

Developed granulations of connective tissue are often com- 
prehended in the term aural polypi, and practically we can 
make no distinction. 

Among the aural polypi which I have examined, only a few 
appeared with hollow spaces on section, among these was the 
above described degenerated membrana tympani. The cavi- 
ties were filled with detritus and fat cells. 

The others were of homogeneous structure, and their papil- 
lary structure could be detected on the external surface.* 

They do not always possess ciliated epithelium, as has been 
said, but this variety may be sometimes distinguished in the 
various lamellae, in the deeper structure, when on the external 
surface none is detected. The lamellated structure is best seen 
by examining the growth under water. 

We are not yet able to say if polypi may be developed in a 
healthy ear, or in a case of simple catarrh of the cavity of the 
tympanum. It is probable, that they have their origin only 
* See Virchow's Archives, vol. 16, p. 71. 



192 AURAL POLYPI. 

after a long continued purulent process. It is also certain that 
an otorrbcea may be maintained for a long time by such a 
polypus, since this will secrete pus very freely, and continue 
the morbid tissue beneath in its irritated condition. 

Otorrhcea, which we cannot check by local treatment and 
cleanliness, will be often found connected with excrescences, 
which, be they never so small, can explain the duration of a 
chronic inflammation of this kind. If you remove them, the 
inflammation immediately closes as if cut off. 

Blood is often mingled with the pus in varied proportion. 

Such growths can grow very rapidly and to a great size. Thus, 
I had a case in a young man with an exacerbation of otitis 
interna with perforation, whom I allowed to go home after the 
subsidence of the acute symptoms, when in six weeks a poly- 
pus formed, reaching out to the meatus, and of which there 
was not the slightest trace when I last saw him. 

Treatment. — We can remove very small growths by means 
of repeated applications of nitrate of silver, even larger, by 
penciling with acetic acid, with tr. opium, with the infus. or tr. 
cantharides, or with creasote, we may cause to shrink away, 
entirely or in part. Such procedures are slow, unsafe, and, 
when with creasote, very painful. 

When it is possible, I would advise the resort to an opera- 
tion, and I do not know any instrument for removing them 
better than Wilde's polypus noose or snare, which I now pre- 
sent to you. 

This consists substantially of a steel shaft, making an angle 
at the middle ; before the bending from its handle it is quadri- 
lateral, in order that a cross-piece may be moved upon it. A 
fine wire is run from this cross-piece the length of the instru- 
ment through rings at the side. The handle has a half ring 
for containing the thumb, by means of. which the whole appa- 
ratus is held, while the cross-piece is drawn back with the 
index and ring-finger. 

The handle and cross-piece are made of German silver. 
Wilde recommends a steel wire, but I use one of silver, as not 
rusting so easily. When we have ascertained by means of a 
sound the position and depth of the polypus, we make a noose 
of the wire, just large enough to encircle the base of it. We 
then pass the instrument in, and the noose about the tumor, 



AURAL POLYPI. 193 

and by means of the cross-piece draw the wire back, and 
thus cut through the polypus. The haemorrhage consequent 
on the excision is generally considerable. After the ear is 
syringed out, we examine it anew, and often find an- 
other polypus, which we should attempt to remove imme- 
diately. 

When these polypus growths extend very 
deeply in the ear, the integument of the au- 
ditory canal is commonly swollen and exco- 
riated, so that in consequence of the increased 
narrowness and sensitiveness of the part we 
are not able to pass the noose to the bottom, 
and are obliged to remove the excrescences 
piece by piece. Since considerable haemor- 
rhage arises after thus cutting off a piece, 
the subsequent examination and re-applica- 
tion of the instrument will be impossible, 
and we will be obliged to subject the patient 
to several sittings in order to remove the 
whole of the morbid growth. 

We learn the value of Wilde's instrument 
in removing a granulation, no larger than a 
pea, which may rest on the membrana tym- 
pani itself, and which on account of small- 
ness and deep position we can scarcely reach. 
In any other way of removal we run the 
danger of severe pain to the patient, and of 
injuring the membrana tympani, but with 
this noose introduced through the speculum, 
and lighted with the concave mirror, it can be 
removed close to the base in a moment of time. 
As I have said, I prefer this method of re- 
moval with Wilde's noose to any other, and 
in only one instance, where a long existing, FlG - 12 - 

dense, and thick polypus reached out to the meatus auditorius 
externus, did it fail me. 

No wire could cut through such a hard body, as this was. I 
could not bring scissors or knife to my assistance, and it seemed 
to me a too formidable operation to be undertaken with the poly- 
pus forceps or pincers. We can never tell beforehand where 

13 



194 AURAL POLYPI. 

polypi of the ear have their origin, and with the forceps we 
may remove a portion of the wall of the cavity of the tympa- 
num, or membrana tympani. 

It may be that the use of this last-named instrument has 
taught many authors to consider the removal of aural polypi 
dangerous, and causing them to warn the profession from 
attempting the operation — for the pincette or forceps are almost 
generally used, and in many cases what comes in their grasp, 
be it polypus or no, is dragged out. 

As many polypi as I have removed, I have never seen other 
than favorable results. In one case, there was a relief from a 
sensation of cerebral pressure after the removal of the growth. 
Even in cases where there is caries of the petrous portion of the 
temporal bone, and the polypi are nothing less than little warts, 
-i have no hesitation in removing them in one way or the 
other. It is true, however, that by these removals we cannot 
protect the patient from a fatal result, especially if we operate 
too late. If the polypus be removed to a certain depth with 
the .wire noose, then the roots can be removed by cauteriza- 
tion with the nitrate of silver after we have cleared the audi- 
tory canal of all secretion, and dried it by means of cotton in- 
troduced with a forceps, or we can bring the remainder to a 
gradual shrinking process by the use of astringents. 

We should never omit such an after treatment of polypous 
growths, else there will be soon a new formation in place of the 
old one. This is the more necessary, when a portion remains in 
the cavity of the tympanum, in the depth of which there can be 
no thought of an operative expedient, at least only to a very 
limited degree. If the different portions of the swollen tissue at 
last separate themselves by cleanliness, and the use of astrin- 
gents, we can remove one or the other of the excrescences by 
means of the noose or caustic. I use a very small piece of 
nitrate of silver for cauterizing the middle ear, and by means 
of the caustic-holder here presented. 

It is astonishing to what a degree sometimes even old and 
severe cases can be improved by means of such a subsequent 
treatment. It has been advised to remove the whole of such 
polypi by means of cauterization, especially with Vienna 
paste in the stick, or with chloride of zinc. I confess I do not 
consider fluid caustics, whose effects you cannot limit, as 



AURAL POLYPI. 195 

applicable for the ear, for the parts can be thus easily injured, 
and unnecessary pain caused. Meniere mentions that he has 
seen necrosis of the bony part of the auditory canal occur, 
when the parts have not been enough guarded. 

Otorrhoea. — This is by no means a disease 
of the ear by itself; it is only a symptom, an 
evidence of disease, — and one that occurs in 
various pathological processes. "We will now 
once more consider the whole subject of otor- 
rhea from a practical stand-point in its full 
importance and common results. 

Otorrhoea occurs after acute and chronic 
otitis externa, myringitis and otitis interna, 
as well as from furuncles in the auditory 
canal, in other words both in external and 
internal affections. Aural polypi may be 
considered as sustaining causes of otorrhoea, 
although they are properly results of inflam- 
matory affections of the ear. 

Purulent discharge from the ear is a very 
common complaint, especially in children. 
This may be accounted for by the fact, that 
it is developed in so many different diseases 
of the ear. It is generally left to itself, and 
therefore lasts a great while. (Among 512 
cases, treated at the New York Eye Infir- F,G - 18 - 

mary by Drs. J. II. Ilinton and Henry D. Noyes during the 
year 1862, 107 are classified as otorrhoea externa, 6 as otor- 
rhoea interna, more than a fourth of all the cases presented.) 

Otorrhoea is generally, both by the laity and professional men, 
considered of no particular importance, and thus it comes to 
be neglected. Sometimes it is even thought the health would 
be injured by checking the discharge. 

In opposition to this general opinion I have often in the 
course of our meeting together called your attention, not only 
to the importance of every discharge from the ear, for 
the affected organ, but also for the general condition and life 
of the patient. In this last-named view we will now consider 
otorrhoea, and the more minutely, since the importance attached 
to the subject here in Germany is exactly the opposite fro.-a 



196 AURAL POLYPI. 

what it claims. (Also true of the United States. It was only a 
few days since that a man in good circumstances, and more 
than ordinary intelligence, came to my office, complaining of 
vertigo and other head symptoms, which I could make nothing 
of until I questioned and examined him as to his ears, ascer- 
tained that he did not hear well from one, had a discharge 
from it at intervals for 12 or 14 years, and yet did not think it 
worthy of mention. I found a perforated membrana tympani, 
he could only hear the watch one inch from the meatus, and 
there was a slight purulent discharge, having its origin in the 
cavity of the tympanum ; other ear normal.) 

As is the case with every bone of the skull, the temporal 
bone stands in the closest relations with the endocranium by 
means of the vessels of the diploe, connecting as they do with 
the dura mater, and its venous sinuses. The integument of the 
auditory canal and membrane of the middle ear stands in the 
same relation to the bones which they cover, being as it were 
their pericranium. 

The purulent inflammation of the ear has a great importance 
for the whole organism, in consequence of the relation in which 
the blood-vessels of the dura mater stand to those of the ear, 
because here, and in the diploe, and in the other cellular 
structures of the temporal bone, we may often seek for the point 
of origin of various constitutional troubles, which* declare them- 
selves under cerebral, typhoid, and py senile symptoms, and which 
appear on the post-mortem table as metastatic abscesses and 
deposits, and as ichorous deposits. 

In all times surgeons have known that every slight appear- 
ing injury of the skull in its hard or soft parts is to be seriously 
regarded, because it often leads to abscesses and inflammations 
in far removed organs, which may have a fatal result. For 
some time it was thought, that this was due to a participation 
of the diploe in the affection. a$Tow by means of the labors of 
Virchow, which have broken an entirely new way to the field of 
science, and made an epoch therein, we know that next to the 
veins of the lower extremity, and of the pelvis, there is no part 
of the human body, so favorably circumstanced for the forma- 
tion of blood-clots as the blood-vessels of the dura mater, and 
the net of capillary vessels communicating with them, which 
pass through the cellular structure of the bones of the skull, 



AURAL POLYPI. 197 

filling them to a great extent, and thus making them organs 
rich in blood. 

The importance of the osteo-phlebitis of the diploe, which 
is so feared by the surgeon, is from purely mechanical causes? 
that is, the vessels of the diploe, if not every where, are here and 
there united to the unyielding wall of bone, and consequently 
thrombi are more easily formed, which extend thenee into 
the sinuses, at length are washed out from here, and excite 
metastatic inflammation in the stream of the pulmonary ves- 
sels, being wedged in there. 

Moreover, purulent masses remain very easily in such small 
cells, and finely washed spaces are broken in pieces, and then 
form, with the aid of extravasations which often form there, a 
foul herd of infection, from which the blood is infeeted, and 
the well-known metastases in the cavities of the pleura and 
joints are excited. 

If, however, when we speak more exactly, a great part of 
the hollow and meshy space of the temporal bone is not to be 
reckoned as diploe, since they contain air, and do not contain 
the thin fluid marrow of the bone, shut in by a narrow set of 
vessels, yet, notwithstanding, we are dealing here with very 
similar anatomical conditions, and we are in free connection 
with the air, just on the other side of the hollow spaces of the 
petrous bone, especially when perforation of the membrana 
tympani exists, which, as is well known, forms the going on cf 
a pysemic process. 

The petrous bone of a child, however, consists almost entire!} 7 
of diploe. In England, it has been for a long time shown how 
often patients suffering from otorrhoea, die in consequence of 
purulent pleuritis, with pysemic symptoms and with lobular 
abcesses of the lungs, and that phlebitis of the-cerebral sinuses 
of the jugular was an explaining accompaniment. 

Lebert first called our attention in Germany to these com- 
mon results of the inflammations of the ear,* and attempted 
to show the deleterious influence of the phlebitis on the blood 
channels, since from this point out, the inflammation must 
extend to the membranes and the brain, or to the jugular vein 
and lungs. 

* Virchow's Archives. B. ix. 1855. 



198 AURAL POLYPI. 

According to Lebert, the inflammation first declares itself by 
a chill which suddenly occurs in the course of an otorrhcea, in 
connection with other symptoms of an incipient typhoid fever. 
Generally such cases are considered as true typhus. The pain 
in the head is much severer, however, confined to one side, and 
is increased on pressure. There is often delirium according 
as are the pain and symptoms of depression. Just so, the 
symptoms of weakness and paralysis of the limbs are of a 
weak and oscillating character. All the peculiar typhus symp- 
toms, such as roseola, ilio-csecal pain, enlargement of the 
spleen, diarrhoea, typhoid bronchitis, etc., are wanting. 

The indolent or weak character of the malady, as it reaches 
out with regularly accelerated pulse, into the first and second 
week, as well as the continued, or at least, occasional pain in 
the ear, gradually calls attention to the ear and brain. If the 
course of the affection be not to sudden death in the form of 
meningitis, in the course of the second or third week distinct 
pysemic symptoms appear. The chills have so distinct a cha- 
racter, that many physicians diagnosticate intermittent fever, 
but a regular interval never appears, while the typhus exhaus- 
tion, the cerebral symptoms, and the remarkable weakness of 
the pulse continue, and gradually the symptoms of metastatic 
abscesses in the lungs and joints appear ; sometimes they 
appear also in the subcutaneous connecting tissue. In the 
first stages of the disease, there is a tendency to constipation ; 
later on, diarrhoea occurs ; the evacuations are irregular ; and 
death, in a comatose condition, generally occurs. 

The course of this disease is either a rapid and acute one, 
which we might call the meningitic, because the central symp- 
toms are most prominent ; or it is of a typhoid and pyemic 
character, malignant to the highest degree, lasting to the fourth 
or fifth week. 

Yirchow has taught us since then, that the putrid material 
in the blood, and not the phlebitis, although of course assisted 
by this, is the chief cause of the disease ; however, I have 
thought it well to give Zeberfs description and ideas of the 
disease in full. It must be clear to you, that these described 
consequences of otorrhcea, whose origin may be deduced from 
emboli and septic infection, that is, from the circulatory system, 
can appear without any caries of the temporal bone. 



AURAL POLYPI. 199 

If we turn now to caries of the temporal bone, as a far more 
common result of purulent discharges from the ear, we find 
that we have already experienced why an ulcerated process in 
the underlying hone, so easily forms from a purulent inflam- 
mation of the soft parts covering these bones. We have also 
found, that in almost every case of caries of the petrous bone, 
we are not dealing with a primary disease of the bone, but 
also with the consequences of a regulated and long-existing 
purulent inflammation of the soft parts ; and that in every 
otitis externa and interna, when the purulent discharge is not 
gradually diminished, the bone always takes part more or less 
in the ulcerated process. Carious affections, on whatever part 
of the body they may take place, as is well known, exert a 
great influence upon the whole organism, and are esteemed as 
very important by every member of the profession, as affec- 
tions which not only excite great local changes and deformities, 
but which often bring the life of the patient into danger by means 
of the blood poisoning, and often leading to a weakened and 
deteriorated condition of the internal organs. 

Caries of the vertebrae and of the bones of the head, are espe- 
cially to be considered dangerous. No bone of the skull is so 
often in a carious condition as the temporal, and the peculiar 
structure of the bone is an especially unfavorable circum- 
stance, so that the prognosis of the caries with its accompany- 
ing otorrhoea is peculiarly gloomy. 

In the seventh lecture, in speaking of the external auditory 
canal, I called your attention to the little distance of the dura 
mater and brain from the upper wall of the canal, the near- 
ness of the mastoid process and posterior wall to each other ; 
and this explains why these parts are so easily brought into a 
state of inflammation. Still more important is the proximity of 
the parts in the cavity of the tympanum, since its lower sur- 
face, or wall, has only a thin plate of bone separating it from 
the internal jugular vein, the largest vein in the head. The 
largest artery of the head, the internal carotid, runs along its 
anterior portion, again, only separated from a soft and often 
wanting plate of bone ; furthermore its roof, or upper wall, 
lies between a covering of mucous membrane, and the 
dura mater, and the sinus petrosus superior. This plate of 
bone is often thinned and even perforated, and often con- 



200 AURAL POLYPI. 

tains, even in adults, an opening—; fissura petrosa squamosa. 
Finally, the internal wall, or wall of the labyrinth, offers but 
slight resistance against an extension of the inflammatory 
process upon the internal ear, and with it, upon the internal 
auditory canal, which is lined with the coverings of the brain. 

Now, I ask, gentlemen, if you know a cavity in the human 
body, and such a small one, which borders in a similar manner 
upon so many important organs, and in which we should so 
anxiously regard purulent processes and their common conse- 
quences ? However, we do not speak here from a merely the- 
oretical and opinion stand-point, but our practical experience 
shows us, and every surgeon knows, that caries of the bones 
of the ear very often excites affections dangerous to life. This 
change in the vessels and in the blood which we have describ- 
ed, occurs quite often ; besides, we furthermore observe inflam- 
mation in the walls of the vessels, the real phlebitis, which 
sometimes leads to perforation of the vessel and- extravasation. 
Considerable haemorrhage has been observed to occur from the 
ear, in consequence of ulceration of the neighboring vessels, 
not to speak of the very slight ones which give to the pus in 
otorrhoea a dark color. 

Inflammation of the brain-substance, the formation of ab- 
scesses in it, and purulent meningitis, accompanied by changes 
in the structure of the upper wall of the cavity of the tympa- 
num, have been observed as the most common of the effects 
of caries of the temporal bone. According to Lebert, who has 
called our attention to this origin of abscesses in the brain, as 
in the ear, about one fourth of these abscesses have their ori- 
gin in caries of the petrous portion of the temporal bone. 

If we look at the cases of abscesses in the brain, scattered 
here and there in the literature of aura] surgery, we will be 
satisfied of their origin, and there is an urgent necessity in 
every post-mortem of such a case to follow Zebertfs advice, and 
examine as to disease of the ear. As a rule, there will be 
found healthy brain substance between the external surface of 
the petrous bone and the purulent masses in the brain, and the 
dura mater on the tegumentum tympani (a thin plate of bone 
forming the upper wall of the cavity of the tympanum) is consi- 
derably thickened. Much more rarely the deposits of pus are 
adjoining, and thus they have the appearance of being metastatic. 



AURAL POLYPI. 201 

This is not the place to go any further into the symptoms of 
abscesses of the brain. I would only recal to your mind, how 
great changes may take place in the brain unaccompanied by 
fever, and with no disturbance of the functions, and especially 
of the intelligence. Severe local pain increasing on pressure, 
is often for a long time the only symptom of an otherwise en- 
tirely latent affection of the brain, and death sometimes occurs 
very suddenly and unexpectedly with convulsive or apoplectic 
symptoms. (At the meeting of the New York Pathological 
Society, held January 23, 1860, Dr. T. G. Thomas, presented 
a specimen of abscess of the brain, resulting from otorrhoea, 
which 1 condense somewhat and insert here :) " A girl about 
fourteen entered Bellevue Hospital on Monday, January 23, 
general health had been good, except that she was subject to 
an occasional slight otorrhoea and convulsions, which were 
clearly of a hysterical nature, which had existed for a year. 
On the seventeenth of the present month, she was seized with a 
violent pain in the ear, which ceased on the twenty-first, and 
pus was discharged. 

" Headache complained of, and pain along the course of the 
spine ; vomiting and occasional delirium set in ; convulsions 
continued. 

" She died in a few days, and the diagnosis between profound 
hysteria and abscess of the brain was not established till the 
post-mortem. 

" Abundant traces of pus were found at the base of the 
brain. At a point just above the petrous portion of the tem- 
poral bone there were fluctuations, and about one drachm of 
pus was evacuated. On incision, pus, on outer surface of the 
brain, evidently resulted from local meningitis." 

" Dr. Bibbins referred to a case which he saw while on Ran- 
dall's Island hospital : A little child had otorrhoea with more 
or less hemiplegia. The Doctor noticed a suspicious purplish 
appearance behind the ear, which looked as if some portion of 
the mastoid process were about to exfoliate ; the child was 
doing well, not confined to bed, was suddenly seized with a 
convulsion and died. 

" Post-mortem showed a large abscess of one lobe of the 
cerebellum." 

(These two cases are full of interest, and amply justify all 



202 AUKAL POLYPI. 

the urgency with which the author insists on a careful consi- 
deration of the ear in all brain symptoms.) 

Otitis and otorrhoea quite often lead to purulent meningitis ; 
and here the anatomical condition allowing the transfer of the 
affection, is commonly clearer and less doubtful, than is the 
case with cerebral abscesses. The inflammation of the cavity 
of the tympanum can extend in two ways upon the coverings 
of the brain, either through the tegumentum tympani, that is, 
upwards, or, inwards, by means of the meatus auditorius in- 
ternus. 

Inflammation of the roof of the cavity of the tympanum, 
and consequently of that part of the dura mater over it, is by 
far the most common result of caries of the ear, as is shown 
by post-mortem sections. This may arise, in good part, be- 
cause this portion of the base of the skull and its changes, 
may be more readily seen in an examination of the dead body, 
while many other changes must be carefully looked after by 
removal of the temporal bone. TTe may, then, question if 
they really often occur, or are only most often discovered. 

I recall to your mind the fissure in the bone which exists in 
the roof of the middle ear, and in the tegmen tympani, and to 
the arterial branch, and the process of tissue which pass through 
this fissure from the dura mater to the mucous membrane of the 
middle ear, and by means of which, each nutritive disturbance 
in the cavity of the tympanum and mastoid process will exert 
a certain effect on the dura mater. I call, further, to your 
mind, the thinning, or rarefaction of the bone, which we have 
found to be quite common here, and which may thin the teg- 
men tympani even to perforation, without any declared caries 
of the bone. It is clear that in a case where there is very little, 
or, perhaps, no substance intervened between the mucous 
membrane and the dura mater, an extension of the inflamma- 
tion is doubly easy to occur. 

The cases, when year-long existing otorrhoea has ended 
fatally, under the form of meningitis, while the roof of the 
cavity of the tympanum was not attacked, but the disease had 
extended from the internal auditory canal, occur very often 
in surgical literature. Very often, however, an exact anato- 
mical description of the intervening parts is wanting. In the 
cases which have been carefully examined, the inflammation 



AURAL POLYPI. 203 

and purulent discharge extend from the middle ear to the laby- 
rinth, and upon the meatus auditorius interims. The wall of 
separation of middle and internal ear, the labyrinth wall of the 
cavity of the tympanum, is thin, and has in it two fenestrse, 
vulnerable points, through which extension of morbid pro- 
cesses is very easy. Itard * speaks of such a case ; and I can 
show you another where the fine ring-shaped band going 
about the base of the stapes, was affected, and thus the puru- 
lent process found its way into the labyrinth. There are also 
many other preparations illustrating this point, especially those 
from Toynbee. If once the vestibulum and cochlea be affect- 
ed, there is nothing between the inflammatory mass and the 
meninges, but a finely permeated lamella of bone, through 
which the auditory nerve sends its soft, hair-like threads into 
the labyrinth, and thus, in the majority of cases,, when the 
labyrinth is invaded, the process extends on to the coverings 
of the brain. 

* Traite des Maladies de l'Oreille. 2 Ed. 1342. Tom. i., p. 210. 



LECTURE XXI 

FURTHER CONSEQUENCES OF OTORRHCEA. ITS PROGNOSIS AND 

TREATMENT. 

Facial Paralysis. — Tuberculosis and Cholesteatomata of the 
Petrous Portion of the Temporal Bone, — The uncertain Progn o- 
sis of Otorrhoea. — The Incision behind the Ear, and Perforation 
of the Mastoid Process. — Prejudice against Local Treatment. 
— {A Case reported by Br. C. JR. Agnew.) 

Gentlemen — We saw, in our last meeting together, what a 
great number of changes in structure nay be developed from 
a purulent process in the ear ; that meningitis purulenta was 
one of its common results, caused by an extension upwards of 
the carious process upon the roof of the cavity of the tympa- 
num ; or, indeed, through the vestibule and cochlea. There 
is still, however, a third way. 

It is well known to you, that occasionally, inflammations 
extend from one point to another along the course of a single 
large nerve, under the form of a peri-neuritis, — an inflamma- 
tion of the sheath of the nerve. 

A continuation of an inflammatory action may extend from 
the cavity of the tympanum, even when the integrity of the 
labyrinth is perfect, through the fallopian canal along the 
facialis nerve, and this nerve is very often involved in the 
affection. To my knowledge, no such connection between 
otorrhoea and meningitis has previously been observed. 

The anatomical considerations of the parts show us, that the 
facialis must be often affected in otitis interna. Sometimes 
the facial nerve runs for a considerable distance on the wall 
of the cavity of the tympanum, and is only separated from its 
mucous membrane by a thin, transparent lamella of bone. 
Sometimes, again, the stylo-mastoid artery, which supplies the 
greatest part of the membrane of the middle ear, takes its 



FURTHER CONSEQUENCES OF OTORRHCEA. 205 

way through the fallopian canal, and gives branches to the 
sheath of the facial nerve. 

Facial paralysis, of various grades, coming after convul- 
sions of the muscles of the face, occurs in the course of inflam- 
mation of the ear, and perhaps a part of the so-called rheuma- 
tic facial paralysis, on more exact examination, will be found 
connected with affections of the cavity of the tympanum. Ex- 
perience teaches us, that there is no such unfavorable progno- 
sis for this affection, as is often given even in our best text 
books of nervous diseases. Even very extended facial para- 
lysis disappears under treatment, and we are able to bring the 
process in the ear to a standstill. 

1 have seen quite a number of recent cases of one-sided 
facial paralysis fully cured by means of the simple treatment 
which we have learne/ for otitis. 

Moreover, we see fi n the described anatomical conditions, 
that the appearance **> paralysis of the facial nerve, in the 
course of an otitis, had. by any means, danger for the life ol 
the patient ; for we cannot, therefore, conclude, that the brain 
is taking part in the affection. Great interference with the 
circulation and increase of secretion in the cavity of the tym- 
panum, can react on these nerves. Moreover, caries, of the 
soft lamella of bone, behind which the nerve runs, which will 
certainly excite facial paralysis if it be not connected with 
more important changes, has by no means such a great im- 
portance. 

The symptoms of this paralysis are well known to you. The 
first, you will often find, is, that the patient does not drink pro- 
perly, and that, as in an awkward child, the fluid escapes at 
the angle of the mouth ; and still more commonly that the pa- 
tient remarks the accumulation of tears in the eye. This last- 
named symptom is almost always the first one complained of, 
and the imperfect carrying off of the tears, which, as is known, 
is accomplished by muscular action — a symptom which is pre- 
sent when the lids close perfectly, and when there is not the 
slightest turning outward of the lower lid, and consequent dis- 
placement of the lower canaliculus. 

Paralysis of both sides seems to be quite seldom. I saw one 
case in connection with aural polypi on each side. The ap- 
pearance here was very remarkable — not only that the face 



206 FURTHER CONSEQUENCES OF OTORRHCEA. 

remained always regular and cold in laughing or crying, the 
under lids with strongly-reddened edges were turned outward, 
and the corners were very prominent and dry from want of 
covering — but there was also a thick swollen under-lip hanging 
down, with the saliva dropping out of the mouth, so that the 
chin was obliged to be supported with a handkerchief; and if 
the patient wished to speak or eat, he was obliged to hold it up 
with his hand. 

I have already called your attention to the fact, that an ob- 
lique position of the uvula and an abrupt bending of it to one 
side, while it is also somewhat drawn up, may be often ob- 
served without any paralysis of the face ; and reversely, in well- 
defined facial paralysis, the uvula may not be affected at all. 

You will often, especially in the French authors, for in- 
stance, Billiet and parthez on Diseases of Children, read of 
the tuberculous inflammation of the petrous portion of the tem- 
poral bone ; and that is a common cau.se of otorrhcea, which 
leads to a fatal result under the name of pyaemia or meningi- 
tis. In the post-mortem examination, we find tuberculous de- 
posits in the ear in great masses, and encysted tubercle in the 
mastoid process : " Matiere tuberculeuse infiltree ou encystee." 
The whole inflammatory process, the ulceration of the mem- 
brana tympani, the otorrhoea, w T ith all its results, was considered 
as coming from the softening of the tubercle, which was con- 
sidered as the primary process. In a more exact examination, 
the most of these cases have another importance. There is 
certainly a tuberculosis of the bones, and we cannot deny the 
possibility of a tuberculous affection of the temporal bone ; 
however, tuberculosis of the bones is a very rare affection. We 
must recollect that thickened pus and softened tubercle resem- 
ble each other very much. You know, gentlemen, that wherever 
pus is collected in any great mass, it becomes thickened and* 
partially calcified, because the property of conglomeration of 
the substance does not allow of its complete breaking up and 
re-sorption. At the most, a part of the fatty covering disap- 
pears ; the remaining calcified and thickened pus forms a 
cheesy mass, such as may be also developed from tubercle. 
These cheesy masses, of entirely different origin, are very often 
confounded, and to the unassisted vision they are scarcely dis- 
tinguishable. Exactly here — in the cavities of the auditory ap- 



FURTHER CONSEQUENCES OF OTORRHCEA. 207 

paratus, in the cellular spaces of the mastoid process — are found 
large masses of pus, which gradually shrink up and form a 
cheesy-like substance ; and perhaps the most of the cases desig- 
nated in the literature as tubercle of the temporal bone are 
such deposits, which owe their origin to a long-continued 
purulent inflammation, and their undisturbed formation to 
a rare use of the syringe. However, even if such forma- 
tions are not tuberculous, they have a very pernicious impor- 
tance, as well for the neighboring parts as for the whole 
organism. 

It is well known that these cheese-like masses also sometimes 
soften and produce an ulcerated condition, from which, accord- 
ing to Professor Buhl's observations, acute miliary tuberculosis 
of the lungs and other organs may be developed.* 

There seems to be a similar condition of things, according to 
Virchovfs examinations of the cholesteatomata, or the mollus- 
cous tumors J. Muller, or Mollusca Contagiosa Toynbee, which 
occur in the petrous bone ; for which names Yirchow advises 
the substitution of the original name (Perlgeschewulste) — pearl 
tumors. These are the mother-of-pearl, shining, onion-like, la} 7 - 
ered tumors, in the posterior section of the temporal bone, 
which extend through the bone to the external auditory canal — 
sometimes, also, in the cranial cavity — as a rule, existing with 
chronic otorrhoea, which brings a fatal result. Examination 
proves that they are composed of flakes of epithelium, min- 
gled in various proportions with cholestearine. It appears, also, 
that here we have to deal with inflammatory products, fur- 
nished for the greater part by the superficial surface of the 
auditory canal, which product is gradually accumulated, dries, 
and by means of continued peripheral growth, develops itself 
more and more into a solid body, which works as an offending 
substance, and by its pressure wears upon the adjoining parts, 
causing them to disappear. Since, then, in the temporal bone 
there is only a vacant space posteriorly, such a dried- up mass 
of secretion provides itself here with a closed space, until, if its 
growth be not disturbed, it reaches on, posteriorly, upon the 
petrous bone itself, upon the sinus transversus, or upwards 
against the brain, and thus produces a fatal result. 

* Vide page 72, Troltsch's Anatomie des Ohres. Wurzburg, 1861. 



20S FURTHER CONSEQUENCES OF OTORRHEA. 

Wherever fatty products are for a long time shut off from 
change of material, or metamorphosis, and become stagnant, 
we see, as is well known, cholestearine formed from it. The 
pus in the ear furnishes a considerable quantity of fat, as does 
also the secretion of the numerous sebaceous and ceruminous 
glands, and the experience of all pathological anatomists, from 
Rokttansky on, as well as that of aural surgeons, prove that in 
the external and middle ear extensive formations of cholestea- 
rine are something very common. 

When we considered the diseases of the external auditory 
canal, we saw that the external surface of a mass of impacted 
cerumen often has a shining appearance, and consists of chole- 
stearine crystals, which may be often found in cerumen. We 
often, also, may see cholestearine as a glistening point in the 
water, if we syringe out the ear suffering from otorrhoea. 

I have sometimes found the deep parts of the auditory canal 
filled with flat, whitish bodies, which can only be removed in 
the course of several days with- the help of a small spoon, and 
which were accretions of epidermis, with the well known rhom- 
boid plates. 

If these tubercle and cholesteatomata may be regarded in a 
common view, perhaps the difference of the formation may be 
derived from their respective points of origin, or the prepon- 
derating localization of the inflammatory process. If the in- 
creased secretion, for instance, takes place in the external ear, 
where, in a normal condition, the glandular and epidermis pro- 
duction is in excess, the circumstances will be more favorable 
for the development of cholesteatomata ; and, to .reverse the 
case, when the middle ear is principally affected, and pus is 
formed in excess of other material, the chalky-like matter will 
be more apt to be developed. 

If we pass now from these last observations, which were by 
no means unnecessary parentheses, back to practical ones, we 
will see, from all points of view which we may take, how care- 
ful and hesitating we must be in our profession, in chronic 
otorrhoea, since we can never, with any certainty, say what 
great changes in structure have taken place. As Wilde very 
well says : " So long as we have a discharge from the ear, we 
are never able to say how, when, or where it may end." Seve- 
ral English Life Insurance Companies refuse entirely to take 



FURTHER CONSEQUENCES OF OTORRHCEA. 209 

risks on persons suffering from otorrhoea ; and this rule seems 
to me entirely correct. Every discharge from the ear can, un- 
der certain circumstances, lead to an affection dangerous to life ; 
and we are not always able to avoid such results. There are 
certain rare cases where patients with otorrhoea recover after 
long-continued typhoid symptoms — chills and metastatic ab- 
scesses — but these are exceptional. (See Zancet, Feb. 1, 1861.) 

However, even in old cases of otorrhoea, we can often do a 
great deal of good, since we may labor against the extension 
of the affection, and sometimes we may even improve the 
hearing. 

Treatment. — This consists, first of all, in removing the secre- 
tion by means of injecting fluids into the ear, and in reducing 
the chronic inflammation by the use of astringent drops ; and, 
if the middle ear be principally affected, by normalizing the 
condition of the mucous membrane of the pharynx, to which 
we must pay due attention in all these cases. By means of 
this treatment, we may even heal declared cases of caries. 
In caries, Ran especially recommends the dropping in of the 
solution of the sulphate of copper : in the beginning, two to 
three grains ; later on, from ten to twelve grains, to the ounce 
of water ; this to be used twice a day. He speaks of it as the 
most reliable remedy, and only doing harm where it excites 
considerable irritation. A slight burning sensation, lasting 
only a few moments, is of no importance. 

In these cases, we must always look out carefully as to the 
general conditiono f the patient. The local treatment, however, 
will be, generally, the most important part of the therapeutics, 
and in perfectly healthy individuals it will be generally enough. 

If sub-acute symptoms appear, we must not omit to practise 
local blood-letting. I recall to mind a case in which, in the 
course of an otorrhoea which had existed for years, a suddenly- 
appearing facial paralysis as suddenly disappeared, after the 
use of Hourteloupe's artificial leech. 

Since a discharge will never cease as long as polypi or dead 
pieces of bone are in the ear, we will often find an operation 
necessary for their removal. There are a number of interest- 
ing cases of the necrosis of great portions of the petrous bone. 
Meniere saw a case (Gazette Medicate de Paris , 1857, No. 50) 
in which, after a long-existing otorrhoea, a piece of bone was. 

14 



210 FURTHER CONSEQUENCES OF OTORRHCEA. 

removed in syringing, which, on more close examination, was 
found to be the whole of the cochlea, coming out with the pus 
without any cerebral symptoms. Wilde relates a case of a 
young lady, who, after the severest symptoms of otitis, with in- 
flammation of the brain, paralysis of the face, one arm and leg, 
had removed from her ear a mass of bone, which consisted of 
the whole internal ear, the cochlea, the vestibule, and the semi- 
circular canals. She recovered from the head symptoms, and 
from the paralysis of the limbs. Meniere and myself have 
both observed cases of nearly complete necrosis of the labyrinth. 
( Virchoirfs Archives, vol. 18, see. 9.) A young man who suf- 
fered for a long time from otorrhcea, with brain symptoms, was 
cured immediately after the removal of a thick piece of bone, 
three centimetres long and two thick, taken from the interior 
of the mastoid process. ( Union Medicale, 1860, No. 52.) 

(Dr. C. R. Agnew, surgeon to the New York Eye Infirmary, 
who founded the present Ear Clinic in that institution, commu- 
nicated a case to number sixteen of the sixth volume of the 
American Medical Times, page 183, which possesses so much 
of interest on this subject, of which Dr. Troltsch is now speak- 
ing, that I give it in full, with the illustration of the specimen, 
kindly furnished me by Dr. Agnew. 

W. C, set. 38, had suffered from otorrhcea from the right 
ear for the greater part of 32 years. The origin of the disease 
was obscure. Considerable sense of hearing remained till 
three years before the case came under my observation, at 
which time an -exacerbation of the aural inflammation, accom- 
panied by prolonged and excessive pain deep in the ear, and 
through the neighboring parts of the head, terminated in total 
loss of hearing in the affected organ, and paralysis of the cor- 
responding portio dura of the seventh pair. 

Several times during the progress of the disease granulations 
sprouting from the depths of the external ear, outcropped at 
the meatus, and were removed by torsion. 

The patient came under my observation for the first time on» 
the 16th April, 1862, presenting evidences of great suffering 
and debility. 

He had suffered greatly for months from growing pain in the 
ear, insomnia, loss of appetite, and dizziness. An examination 
of the external ear was effected with great difficulty on account 



FURTHER CONSEQUENCES OF OTORRHCEA. 211 

of its excessive tenderness. The concha, swollen and inflamed, 
was elevated by a dense inflammatory tumefaction, circum- 
scribing the external meatus, extending backwards over the 
mastoid process, and forwards along the zygoma. Projecting 
from the meatus was a large pear-shaped polypus of a dense 
fibrous character, bathed by a constant flow of stinking pus. 
Desiring to get to the bottom of the case, I placed the patient 
under chloroform, and removed the polypoid mass by means 
of a wire snare. In attempting to push the snare to the bot- 
tom of the meatus, I encountered a solid obstacle in the region 
of the middle ear, which subsequently proved to be the seques- 
trum, represented by the accompanying wood-cut. The cali- 
bre of the external meatus had been greatly reduced by boggy 
swelling of its soft parts, so that I was compelled to make as 
free an incision as possible to enable me to reach the seques- 
trum with a pair of small dressing forceps. Having got the 
body in the grasp of the forceps, a slight rocking motion with 
traction enabled me to extract it. 





c 

It will be observed that the sequestrum includes the wreck 
of the labyrinth. The cochlea is shown laid open by caries, 
and two of the semicircular canals are seen in part. The loss 
of hearing and paralysis of the seventh pair were explained. 
Two views in facsimile are given of the sequestrum in the 
wood-cut, and an attempt has been made by the artist to repre- 
sent the eroded appearances. 

The remains of the anterior semicircular canal are indicated 
by the letter C, the cochlea B opened by caries shows the la- 
mina spiralis. The vestibule, E, A, D, is bereft of its furniture, 
and almost obliterated. After the operation, the patient rapidly 
regained his health, and by the 3d of January, 1863, the exter- 
nal meatus had become closed by cicatrization. The paralysis 
still remains. 

In September, 1863, I was informed by Dr. Agnew that the 
patient was doing well, no head-symptoms, no otorrhoea, and a 
minute meatus externus is seen.) 



212 FURTHER CONSEQUENCES OF OTORRHCEA. 

When in the course of an otitis, with or without otorrhcea, 
the mastoid process begins to be painful, and tender on pres- 
sure, and the swelling and redness of its covering indicate an 
inflammation of the bone, lying under, a free incision of the 
soft parts down to the periosteum is often of great use. Wilde 
recommends this procedure as one by which a process danger- 
ous to life may be restrained, and I have had opportunities to 
test the use of such incisions. 

(In the New York Medical Press, vol. ii., p. 833, occur some 
clinical remarks of Prof. A. C. Post on this subject of post- 
aural inflammation, which show a full appreciation of the 
affection. 

" Patient, set. 30, came to the Professor's clinic on account of 
pain in his ear and about it. 

" "We have here, gentlemen, a swelling behind the ear involv- 
ing the deeper tissues, called a post-aural inflammation. It is 
very dangerous in its character, if not properly attended to, 
being of the same general character as a paronychia. If not 
relieved by incisions it will involve the bone, causing necrosis, 
extend to the encephalon, and with great suffering cause the 
death of the patient. I once attended a young girl approach- 
ing maturity with prse-aural inflammation, an affection of the 
same character in front of the meatus auditorius externus. It 
went on to the destruction of the anterior margin of the exter- 
nal meatus, but the patient recovered with a loss of bone. A 
sister of this same patient was attacked with the same affection, 
and died from its extending to the encephalon. She was not 
under my care, but the case came to my knowledge. 

" Incisions should be made fairly down to the bottom of the 
parts, so as to allow the matter free exit, and to relieve the 
tension. Such an incision was then made between the course 
of the occipital and posterior auricular branches of the exter- 
nal carotid. Pus was found next to the bone." 

A similar case occurred to the editor while temporarily in 
charge of the ear clinic of Dr. J. H. Hinton, of this city. The 
incision made by me was followed by instant relief to a pain 
of an agonizing nature, and the case has progressed well. The 
comparison of the affection by Professor Post to Paronychia, 
conveys in a few words the whole idea of diagnosis and the- 
rapeutics, for this trouble.) 



FURTHER CONSEQUENCES OF OTORRHCEA. 213 

The incision must be long enough and made with a power- 
ful hand, in order that the periosteum may be divided in its 
whole length. The swollen condition of the parts often ren- 
ders the depth to which the knife may reach, very conside- 
rable. The incision should be made parallel with the 
line of the auricle, so that the posterior auricular artery may 
not be injured. The haemorrhage may be considerable. If an 
artery spouts, it may be twisted ; even if there be no evacua- 
tion of pus, the discharge of blood will afford great relief, and 
better the condition very much. If the circumstances require 
delay, apply poultices. (I can imagine few circumstances 
admitting of delay.) 

If the symptoms indicate the deeper situation of the diseases 
I would not hesitate to perforate the bone, and thus evacuate 
the pus by making an artificial fistula behind the ear. This 
perforation of the mastoid process, in case of purulent collec- 
tions, has been performed only eight times, so far as I know, 
once by myself, and always with good results ; sometimes 
actually saving life. 

If this operation stand somewhat in bad repute among sur- 
geons, it is because in the last century it was recommended as 
a remedy in all kinds of deafness, while it is never indicated 
but under the above-named circumstances. How often good 
methods of cure are disregarded and forgotten, because of 
improper use ? In most cases, the incision behind the ear will 
be sufficient, and if the necessity occurs, the perforation may 
be performed two or three days later. 

In the only case in which I perforated the mastoid process, 
I did it with an ordinary blunt probe ; when the bone is thick, 
we can use a small trephine. In order to avoid injury to the 
dura mater and sinus transversus, we must place the instru- 
ment on the same line with the meatus, and work the instru- 
ment lightly forward in a horizontal direction. The greatest 
care must be exercised in the operation. When we have 
removed the pus in this way, we can remove the subsequent 
collections by squeezing, and keep the fistula open by a tent 
of lint. 

You will still allow me a few words, gentlemen, concerning 
the prejudice felt even more by the profession than the laity, — 
a prejudice which certainly owes its origin to us, — against the 



214 FURTHER CONSEQUENCES OF OTORRHCEA. 

local treatment of otorrhoea, as having a bad effect upon the 
general health. I have always found the opposite to be true, 
—that with a gradual diminution of the aural discharge, the 
general condition is improved ; and that very many persons 
lose their lives because the process is allowed to go on. 

When, for the first time, I saw an otorrhoea, which had 
existed for years, disappear after the removal of a polypus, so to 
speak, in the twinkling of an eye, I took the precaution to order 
laxatives for a few days : or in other cases, the establishment 
of an issue on the arm. One patient, being tired of the un- 
cleanliness, allowed it to heal ; another did not follow my 
advice, and with no evil results. Since then, I allow over- 
anxious persons to drink " bitter wasser" for some days, in order 
to quiet their fears, because I have learned that such a sudden 
cessation of the discharge is not productive of evil results. 

When there exists no polypus, foreign body, sequestrum, or 
the like, and the otorrhoea, with our best efforts, will not heal, 
we will be very likely to regard each view of the surgeon 
against the sudden stoppage of the discharge, as very like the 
idea of the fox in the fable, when the grapes were beyond his 
reach. 

We can only heal a discharge from the ear with good results, 
when we know the cause of the malady ; since this is often 
wanting, the treatment often fails to do the patient any good, 
and then the idea occurs to both the patient and the physician, 
if, on the whole, it were not better to leave the whole thing to 
good Dame Nature. Let it be added to this, that a sudden lessen- 
ing of an otorrhoea appears at the same time with some gene- 
ral malady, and it is immediately concluded, that this sudden 
stoppage of the discharge is the cause of the disease. Effects and 
causes are here confounded ; another reason must be sought 
for. The discharge ceased, because from some kind of an 
in J ul 7> possibly from the use of an unfitting, too strong ear- 
wash, an acute inflammation of the ear has set in. 

There is less purulent discharge from the ear, because it has 
suddenly made a way inward, or because by some mechanical 
hindrances it has been shut up in the depth of the ear. These last 
reasons indicate a worse condition, and an affection of the 
brain. 

But, for the justification of the general practitioner, it must, 



FURTHER CONSEQUENCES OF OTORRHCEA. 215 

finally, be remarked, that this belief, that local remedies can 
easily do harm in otorrhoea, is due to the teachings of aural 
surgeons themselves, to the writings of the otherwise worthy 
Frenchmen, Du Verrey (1863), and Hard (1838). 

(Through the courtesy of Mr. T. Edwards Lewis, student of 
medicine, I am furnished with the note of a case, presented at 
Professor Post's clinic in the university, which illustrates in a 
striking way, the importance of a " discharge from the ear," 
which so many practitioners tell patients that their children 
will grow out of. A little inquiry among the surgeons of our 
city has surprised me, showing the extreme frequency of sup- 
puration within the cranium, resulting from otorrhoea and 
caries of the temporal bone. Dr. Thaddeus M. Halsted, one 
of the surgeons to the New York Hospital and New York 
Eye Infirmary, says, he remembers eight cases of the kind 
Professor Post, in his ordinary clinical lectures on otorrhoea, 
alludes to a number of interesting ones, and thus one might go 
on citing these examples treating such a warning lesson. 

A woman, 23 years of age, born in England, presented 
herself on the 10th October, 1863, complaining of intense pain 
in and about the right ear. She was in a weakened, anaemic 
condition, could scarcely stand alone, and was failing rapidly. 
There was a partial paralysis of the muscles, supplied by the 
portio dura of the seventh pair on the right side, and the Pro- 
fessor spoke of the connexion of the portio dura and mollis 
in the meatus auditorius internus, and that the nerves were 
probably destroyed by suppuration in this case. The third 
pair was intact, as shown by the ability to lift the lid, although 
not to close it perfectly, that action being effected by the orbi- 
cularis supplied by the portio dura. 

" For a period extending from early childhood up till this 
time, the patient has had a discharge from the ear at varying 
intervals. Just now there is no discharge, but intense pain in 
the region of the ear, and general symptoms of cerebral con- 
gestion. 

" Patient vomited in the cars on coming to the clinic. This 
otorrhoea has never received any continued rational treatment. 
This last attack was superinduced from cold from a draught 
of air, caught about a month since. 

" An unfavorable prognosis was pronounced. The patient 



216 FURTHER CONSEQUENCES OF OTORRHCEA. 

was, however, seen and prescribed for daily by Mr. Lewis, nnder 
the direction of Professor Post. The cerebral symptoms in- 
creased, and on the night of the seventeenth, seven days after 
coming to the clinic, patient died, being for some time previous 
in a semi-comatose condition." 

Here should follow the record of the section of the cadaver, 
but permission for a post-mortem examination was persistently 
refused by the friends of the patient.) 



LECTURE XXII. 



NERVOUS DEAFNESS. 



Absence of JEJxact Anatomical and Clinical Proof of the Affec- 
tion. — A Case of Nervous Deafness in an Artillerist. — Affec- 
tion of the semi-circular Canals with Cerebral Symptoms accord- 
ing to Meniere. 

Gentlemen — An intelligent ophthalmologist once described 
Amaurosis, or nervous blindness, as that affection of the eye, in 
which neither patient nor physician is able to see. 

Since the discovery of the ophthalmoscope this definition has 
lost its point, for with its aid we can recognize many different 
changes in structure in cases of amaurosis. 

Yet, we may avail ourselves of this definition for nervous 
deafness. Since this is that disease of the ear, in which the 
patient does not hear, and the physician does not see why. 

We must decide that a patient is affected with nervous deaf- 
ness, when we can find no change in the material structure of 
the auditory apparatus, from which the diminution of the power 
of hearing can be deduced. 

Of course, such a diagnosis requires a very exact knowledge 
of the parts, and a well founded capability of observing slight 
deviations from the normal ; and nowhere is the degree of ad- 
vancement of the physician, and the stage of development of 
science, better shown than in nervous diseases. 

With every increase of our knowledge of the morbid pro- 
cesses, taking place this side of the labyrinth, and with every 
improvement of our method of examination, the field of ner- 
vous affections of the ear becomes smaller. 

The diagnosis " nervous deafness" will be the oftener made, 
the less the surgeon is able to distinguish the different affec- 
tions, the less he understands how to examine the affected por- 



218 NERVOUS DEAFNESS. 

tions, and the less knowledge lie has of the pathological 
changes of the external and internal ear. 

Examinations of other fields of science, as well as the history 
of our art, teach us that in proportion to the improvement 
of the objective modes of examination of nervous complaints, 
and the progress of science, together with, the influence of 
pathological anatomy, the diagnosis " nervous" becomes, to a 
certain degree, a chance hit, a declaration of not knowing and 
not finding, and is only a common one for those who use it 
willingly. 

I will call only one department of disease to your recollec- 
tion, in which we were formerly contented with the frequent 
diagnosis " nervous affection," — affections of the female genital 
system. Now, these are found to depend very often on morbid 
material changes, and we are able to make a more favorable 
prognosis to affections of the parts, when properly treated, 
which were formerly regarded as incurable. 

Then, gentlemen, let us confess, that we only name those 
affections "nervous," which we do not comprehend, and which, 
as a rule, we cannot improve. 

William Kramer, one of the oldest and most distinguished 
aural surgeons of the present time, says, that while formerly 
he considered nervous affections to be the most common of all 
of the ear, almost exceeding fifty per cent, of all the cases, 
now, with the advance in pathological anatomy, especially 
in the study of exudations, he has reduced their frequency to 
a minimum — four in a thousand.* 

Let us see, now, what we can say with reference to the 
anatomical and clinical facts in their relation to nervous 
deafness. 

Its anatomical substratum must necessarily, before all tilings, 
be sought for in the labyrinth, in the auditory nerve and its 
source of origin, and finally in the brain ; whose disturbances 
of circulation will always declare themselves on the inner ear, 
since the vessel carrying blood to the labyrinth is a cerebral 
artery, and the veins, vense auditorise internee, empty into the 
venous sinuses of the dura mater. Eudolph AYagner says : 
" One of the most humiliating tests of the incompleteness of 

* See " Kramer's Aural Surgery of the Present Day." Ohrenheilkunde der Gegen- 
wart Berlin. 1861. Page 39. 



NERVOUS DEAFNESS. 219 

our knowledge of the functions of the parts of the brain is this 
— that the central organ of hearing is entirely unknown, 
while we certainly know that for sight. I think it probable 
that it is to be sought for in the medulla oblongata spinalis." 
Zeitschrift fur ration. Medezin. 1861. Book 10, page 277. 

Very few morbid changes have as yet been observed in the 
labyrinth, which fact is due to the unexplored condition of 
this branch of science ; and we are not certain if the processes 
which have taken place in the middle ear are primary, and 
those of the internal ear only secondary. And furthermore, its 
condition may depend on the greater or less quantities of oto- 
lithes, and the presence of the often-spoken-of black pigment, 
which, in almost every healthy ear, may be found in different 
parts of the covering of the labyrinth. 11 

Many appearances may (Upend on post-mortem appear- 
ances, which very quickly show themselves in these parts, and 
make the decision difficult. 

Toyribee, who hat made the greater number of sections 
of ears, gives, as among the appearances of the labyrinth, the 
following : — extravasations, exostoses, thickening and atrophy 
of the integuments, insufficiency of the semicircular canals, 
hypertrophy of the cochlearis muscle. However, his descrip- 
tions are extremely short and fragmentary, and he does not 
appear to attach much importance to u nervous deafness" in 
Kt-book. 
1 MoUni speaks much more of the diseases of the internal 
ear. In almost every temporal bone of deaf persons which 
cammed, he found morbid changes in these parts, and 
therefore, he, like hi \cept that his opinions are based 

on anatomical grounds, considered nervous deafness the most 
common of the diseases of the ear.f 

lie found thickening of the integuments, calcareous forma- 
tions, and at one time a fibro-muscular tumor, absence and 
ss of otolithes, collections of pigment, amyloid degene- 
ration of the auditory nerve, and once a sarcoma of the 
nerve. 

Clinical tacts are wanting for the confirmation of this dia- 



* Vide Kolliker's Geweblehre. 1852. § 234, and § 235. 
\ Yirehow's Archives?, book 22, hp. 1-2. 



220 NERVOUS DEAFNESS. 

gnosis, nervous deafness, and we must for the present adhere to 
those facts, which are in turn wanting in anatomical proof. 

Thus it is often said by sick people, that after somewhat large 
doses of quinine they have suddenly been attacked by a vio- 
lent singing in the ear, accompanied by considerable difficulty 
in hearing : a distress, which generally — although not always — 
entirely disappeared after a while. Generally these pheno- 
mena appear, accompanied by other narcotic or poisoning 
symptoms. They must, therefore, no doubt, be attributed to 
the effect of Quinine upon the brain, or upon the vascular sys- 
tem. In this connection also belongs that transient deafness, 
which von Scanzoni several times observed to appear over the 
whole body, after the application of leeches to the vagina, usu- 
ally with a general vascular excitement, and with the eruption 
of Urticaria. Hysterical and chlorotic people often experi- 
ence peculiar vacillations in the power of hearing, which toge- 
ther with the negative state in the ear are in such singular 
sympathy with the general health, and the sexual functions, 
that they can only be denominated " nervous " phenomena. 
As in fainting, a transient singing in the ear, together with diffi- 
culty of hearing, appears, so also is it the case with the longer 
enduring anaemia of the brain after large loss of blood. To 
this may be added, in part at least, that hardness of hearing, 
which is observable in people suffering from typhoid fever with 
negative, objective symptoms, a difficulty which generally dis- 
appears of itself in convalescence with the increase of the 
general health, or under an invigorating treatment. 

As is well known, severe concussions, or a fall on the head, 
excite " nervous" deafness. Of the former class I am able to 
relate to you, among other instances, a very striking one from 
my own experience. In the summer of 1858 an artillerist, 
Martin Baumann from Ansbach, 21 years old, was brought to 
me by the military surgeons Drs. East and Hausner. He him- 
self a strong, and as yet always healthy man, states that he 
received in his ninth year a blow on the ear from his father, in 
consequence of which he heard nothing in that ear for eight 
days. "Whether he had any suffering with it, or on which ear 
he received the boxing, he cannot say. But he asserts quite 
confidently that he was able to hear perfectly well after that, 
until within two days. He states, that two davs before, during 



NERVOUS DEAFNESS. 221 

artillery drill, he was connected with the service of a six- 
pounder gun ; and that he stood during the firing about two 
feet from the muzzle, his face fronting the gun. The first six 
shots, which followed each other at intervals of about ten 
minutes, called up a strong and unpleasant concussion. At 
the seventh shot he felt an extremely violent pain in both ears, 
as if a javelin was stuck through his head. From this moment 
he was deaf. This violent pain lasted about two hours. After 
that he experienced only a strong singing, together with a dead- 
feeling in his head. The patient, who spoke unnecessarily loud, 
understood only when spoken to slowly and distinctly through 
an ear-trumpet ; and he did not hear a loud ticking clock, 
on the mastoid process, but only on the frontal bone ; and then 
he 6tated that he did not fear, he only felt a gentle concussion. 
In his organ of hearing, there seemed to be nothing out of 
order, omitting a slightly elongated red spot in the back half 
of the right membrana tympani behind the middle of the 
lrammer. This spot, which was a slight linear slit, or small 
extravasation, rapidly grew paler, and continually smaller, and 
after two weeks it was scarcely discernible. Air blown in by 
a catheter entered easily and clearly from both sides, without 
any further phenomenon: except a dull feeling in the head, the 
sick man was perfectly well. He had appetite, and all his func- 
tions were normal. His treatment in the military hospital con- 
sisted at first of calomel and jalap in aperient doses, simul- 
tanonsly with cuppings on the neck : — afterwards a rubbing of 
tartarized antimony salve behind the ears. The condition 
remained steadily the same, except that the patient gradually 
screamed less boisterously. Twelve days after the accident I 
commenced a treatment by faradization of the ears, first with 
a quite weak and brief current, slowly increasing the strength 
of the current, and the duration of the treatment. The nega- 
tive pole was held in the entrance to the ear, which was filled 
with water, — the positive pole rested on the moistened mastoid 
process, and afterwards on the neck also. After the treatment 
the buzzing was a little stronger for a time. A violent pain in 
the ear accompanied stronger currents, and also some injec- 
tion on the malleus. This electric treatment was continued 
daily for six weeks with slight interruptions without any change 
of the condition. The patient felt as well before as after, except 



222 NERVOUS DEAFNESS. 

the continued deadness in the head. Simulation, which must 
be guarded against among soldiers, was not to be thought of 
judging from his whole conduct. Moreover, during the whole 
time of his treatment he was continually watched in the mili- 
tary hospital : and also after he had been dismissed as a soldier 
to his home, where he followed his trade as a glove-maker. 
Keport was made at the year's end, that his deafness continued 
unchanged, although it became soon less apparent as the very 
intelligent patient quickly accustomed himself to observing 
the motions of the mouths of speakers. 

I believe, it can scarcely be explained differently than that 
this violent explosive concussion, in this perhaps peculiarly pre- 
disposed person, had brought about a paralysis of the acoustic 
expansion, either directly (as sometimes the destruction of the 
optic functions is reported by a sudden dazzling), or indirectly 
in consequence of haemorrhage in the labyrinth. 

If deafness occur after a fall on the head, it may often con- 
nect itself with changes in the brain, or with a fracture of the 
base of the skull, which, as you know, winds its way frequently 
through the temporal bone. For instance, there lives here a 
whitewasher, an extremely jovial fellow, who many years ago 
fell from a church-steeple, which he had to whitewash. He lay 
for a time in the Julius Hospital, in consequence of a fracture 
of the skull : and, since this accident, is so stone-deaf that he 
assured me, that for the sake of trial, he had placed himself 
near a cannon being discharged, and that he had certainly 
felt a concussion in his head and feet, but that he had heard 
nothing of the report. Such cases of absolute want of appre- 
ciation of sound are extremely rare ; for even deaf and dumb 
people frequently react under a strong noise ; for instance, the 
report of a percussion-cap, or the ringing of a bell near their 
head. 

One of the most worthy contributions to the science of nervous 
deafness we owe to late French investigators, especially to Dr. 
P. Meniere of Paris Deaf and Dumb Institute, who unhappily 
died at the beginning of this year, and who was altogether one 
of the most meritorious workers in the province of aural sur- 
gery. Meniere, in the year 1861, drew attention to a series of 
most remarkable diseases, which appeared under the form of 
an apoplectic congestion of the brain, with sudden vertigo, 



NERVOUS DEAFNESS. 223 

vomiting, great singing in the ears and a fainting condition, and 
which frequently left behind a certain impediment in motion, 
a continuing unsteadiness in standing and walking, and thus 
gave the surgeon from the beginning an impression of a conges- 
tive affection of the brain ; while through the constant recurrence 
of all these disturbances, and through the remaining of a gene- 
rally very remarkable difficulty in hearing for which no assign- 
able change in the ear could be found, they decidedly proved 
themselves to be indicative of an affection of the inner part of 
the ear. The affection of the hearing proved itself to Meniere, 
despite all local and general methods of treatment, to be incura- 
ble ; while the universal disturbances, which appeared so threat- 
ening, disappeared gradually, and the patients afterwards enjoy- 
ed complete health. Meniere, as a warrant for the presenta- 
tion of this new form of disease, communicates a considerable 
series of histories of patients, abridges his experiences on this 
point in the following propositions : 

1. A hitherto entirely sound organ of hearing may suddenly 
become the seat of functional disturbance, which consists in a 
humming in the ears of very varied nature, now continuous, 
again intermittent, to which a decline of various degrees in 
facility of hearing soon joins itself. 2. These functional disturb- 
ances have their seat in the inner part of the auricular appa- 
ratus, and have the power of calling up apparent brain fits, as 
vertigo, stupefaction, unsteady motion, whirling motion, and 
sudden concussion, beyond which they are accompanied by in- 
clination to vomit, actual vomiting, and by a sort of fainting 
condition. 3. These fits, which occur after free intermissions, 
are always followed by a greater or less degree of difficulty of 
hearing, and more frequently the power of hearing becomes 
suddenly completely annihilated. 4. It is most probable that 
the material change which lies at the foundation of these dis- 
turbances has its seat in the semicircular canals. 

This view of the conjectural seat of the disease in the semicir- 
cular canals, Meniere supported partly by a similar case, on 
which a post-mortem was had, partly by certain physiological 
experiments. Concerning the first, the case is of a young girl, 
who in a nocturnal journey on the imperial of a diligence during 
her menstrual period, caught a severe cold, became suddenly 
completely deaf, experienced thereby a continuous vertigo, at 



224 NERVOUS DEAFNESS. 

each attempt to move vomited, and on the fifth day died of the dis- 
ease. The brain and spinal cord were entirely sound, and the ear 
showed no pathological change whatever, except in the semicir- 
cular canals, which were filled with a red, plastic lymph, a sort 
of bloody exudation, of which scarcely any traces showed them- 
selves in the vestibule, and none in the cochlea. The physio- 
logical experiments, which must be here mentioned, are those 
of Zlourens, who, as is known, after the injury of the semi- 
circular canal, in doves and rabbits, noticed different kinds of 
dizzy motions, unsteadiness in moving and resting with evi- 
dent loss of equilibrium, and more frequent tumbling over. An 
observation of Signol and Vulpian, recently laid before the 
society of biology, is of great importance to this topic. It is of 
a rooster, who in a combat with his equal, presented precisely 
the same disturbance of equilibrium, and other manifestations 
in movement and rest, as Flourens noticed after the injury of 
the semicircular canal, and the like, and as Meniere reported 
in the former cases. At the post-mortem section every abnorm- 
ity of the brain and its integument was wanting ; on the contra- 
ry, there was a partial necrosis of the bones of the temples, by 
which a greater part of the inner and middle ear of one side, as 
also the semicircular canals, were for the most part destroyed. 
This instance seems, indeed, to a certain degree to speak for 
the correctness of Jblourensh discovery, and serves at all events 
as authority for the assertion that diseases of the inner part of 
the ear are calculated to call forth identically the same results 
as the direct experimental injuries of this organ. 

These communications are extremely worthy of notice, and 
incite us to exact observations and experiments in this direc- 
tion. The subject, nevertheless, may in no manner be con- 
sidered as concluded, as manifold demonstrative dissections 
and various corroborations of the facts of observation are neces- 
sary to it. I myself remember, in my somewhat extensive 
practice, only a single case which was analogous to that of 
Meniere, although here also certain symptoms were not to be 
rejected, which implied a catarrhal process in the tympanum. 

In addition, we must remember that in the symptoms above 
introduced, one at least, vertigo, is called up by various pro- 
cesses of diseases of the ear : especially by the stoppage of the 
meatus by ear-wax or other material, by acute catarrh and 



NERVOUS DEAFNESS. 225 

purulent processes in the cavity of the tympanum. "We have 
seen that, if these conditions cause vertigo, we must consider 
this preeminently as a symptom of abnormal pressure, which 
is made upon the drum, and therewith upon the chain of 
little bones, or upon the last articulation of the latter, the stapes, 
and its fenestra. The increase of the pressure, which was pro- 
duced in a peripheral manner, and which was transferred from 
the stapes to the vestibulum, must necessarily place the semi- 
circular canals in an abnormal state of pathological irritation, 
and this condition might be designated as the same with all 
these different forms of disease of the ear (which are followed by 
vertigo) : and perhaps it is of importance only for the extent 
of the appearances and their further results, whether the irrita- 
tion is one transferred from the periphery or arising mainly in 
this division of the labyrinth itself. In any event we must, 
for the present, be on our guard not to infer from similar 
instances that there is a primary affection of the semi-circular 
canals or of the nervous apparatus. We must be doubly care- 
ful in the supposition of a nerve us cause for affections of the 
ear, because catarrhal processes of the tympanum, pressing 
upon the wall of the labyrinth and the two fenestrae, often 
localize themselves, and a high degree of deafness ap- 
pears under manifest symptoms of irritation of the inner 
part of the ear ; while one of the chief points of the diagnosis, 
the changes on the tympanum, are little manifested, and the 
remaining inferences which result from the condition of the 
mucous membrane of the throat, and the use of the catheter, 
frequently exist only in the beginning of the affection. That 
diseases of the middle ear often assert themselves in a second- 
ary manner on the labyrinth we noticed before, where we 
found in every case of catarrh of the Eustachian tube, in con- 
sequence of one-sided atmospheric pressure, which weighed 
upon the tympanum, that the stapes is pushed further inwards, 
and thus the fluid of the labyrinth is exposed to an increased 
pressure, which condition, if somewhat longer continued, will 
leave behind it lasting disturbances of the nutritive supply of 
the ear. 

The degree of functional disturbances cannot be determined, 
in the Ear, as in the Eye, where even when the media are ob- 
scured, we can make an exact conclusion as to the condition 

15 



oo {3 NERVOUS DEAFNESS. 

of optic nerve and retina. The physiology of the faculty of 
hearing has, unhappily, thus far, not taught us what degree of 
deafness can arise from simple peripheric causes, and from 
what point we must suppose an affection of the nervous appa- 
ratus. Even if we can connect certain higher grades of deaf- 
ness, from universal hypothetical grounds, with a lack of per- 
ceptive organs, still every intimation of a settled boundary line 
is wanting, before which peripherical interference with the 
conducting of sound is possible, and behind which only dulness 
of the brain or the acoustic nerve and its ramifications is 
imaginable. It is certain, and established experience proves, 
that primary processes in the cavities of the tympanum pre- 
suppose a high degree of deafness, perhaps with an inclusion of 
the influence which they exercise through the fenestra in a 
mechanical way upon the contents of the inner part of the ear. 
Let us consider, by way of illustration, a case where the stapes 
is immovable and surrounded by masses of bone ; consequent- 
ly, the fenestra ovalis is quite shut ; furthermore, the mem- 
brana tympani secunda is converted into a thick, inelastic or 
chalky plate, and the entire canal of the fenestra is filled with 
a compact plug of connective tissue ; nevertheless, the labyrinth 
may still be sound, but the acoustic fibres can be reached only by 
those vibrations which are transmitted to them through the 
denser parts, viz. the skull bones. 

Up to this time pathological anatomy, clinical experience, the 
consideration of the nutritive position of the labyrinth, and 
finally, the reflection that in other organs, especially in the eyes, 
disturbances of the nervous apparatus are proportionately in- 
frequent—have all taught us that the seat of disease in the ear 
is far less frequently to be sought in the labyrinth than in 
the structures which transmit sound. However, this view 
avails only salva meliori, as the lawyers say, ue. so long as 
we know nothing better, and so long especially as manifold 
pathologico-anatomical observations, susceptible of proof, 
do not demonstrate a greater abundance of changes in the 
inner part of the ear as a reason of the disturbance of the 
mind. 

If there are in addition to the abnormities of the inner ear any 
changes whatever existing, for instance, in the cavity of the 
tympanum and the drum, the diagnosis will be still more diflS- 



NERVOUS DEAFNESS. 227 

cult, for we possess no mark which points certainly and ex- 
clusively to an integrity or affection of the nervous apparatus. 
We shall, in the next chapter, speak of the circumstances 
attendant on the hearing of a watch, through the bone of the 
skull, the so-called " knockenleitung" conducting power of the 
bones, the obstructing of which has been denominated a 
pathognomonic sign of the disease of the labyrinth. 

Where a doubt exists whether we have to do with a catar- 
rhal or a nervous difficulty in hearing, whether with disease of 
the middle or the inner part of the ear, you will do well, in my 
opinion, in every relation, scientific as well as humane, to con- 
sider the first form the more probable one, especially since in 
this event a proper treatment, in most instances at least, is able 
to stop the progress of this evil, while real appearances in the 
inner part of the ear, if not dependent upon anomalies of blood 
and circulation, are, as a matter of course, almost entirely 
removed from our therapeutic interference, and we shall be 
obliged to " let things go as it pleases God. " 

I did not mention above the diseases of the labyrinth, which 
were presented by Erkard, for I am sure that if you take up 
the " Rationelle Otiatrih" after an examination of a few pages, 
you will be convinced that this book makes similar pretensions 
to objectiveness of statement and sobriety of observation with 
Munchhausen ] s descriptions of his hunting tour ; and you will 
find as regards the correct working up of material, the arrange- 
ment or the consequent direction of the thoughts, that it is 
almost unique of its kind in the medical literature of this cen- 
tury. You will be astonished if I tell you that this book has 
been imposed upon sober men as true science, and in respecta- 
ble Journals criticized in a manner most worthy of acknowledg- 
ment ; this is comprehensible only from the truly childish 
ingenuousness of so many physicians who have been the read- 
ers of this book, and the critics who have reviewed it. 



LECTUEE XXIII. 

Otalgia.— Deaf-Mutism.— The Application of Electricity in the 
Treatment of the Ear. — Hearing Contrivances. 

Gentlemen — As we have recently considered nervous deafness 
and its manifestation, we have still to mention, in a few words, 
nervous ear-ache, or otalgia. 

Nervous ear-ache, which does not depend upon inflamma- 
tory action, Otalgia nervosa, is, at all events, a very uncom- 
mon disease, and appears infinitely less frequently than is 
generally supposed in the ordinary practice, in consequence 
of a generally imperfect examination of the ear. There is, 
nevertheless, a pure neuralgic form of ear-ache, and it is, in its 
severity, an extraordinarily painful disease. It most generally 
occurs with the decay of a molar tooth on the same side, or 
proceeds from the same. In one case of that kind, which I 
knew, the pain in the ear disappeared immediately after the 
extraction of the tooth ; in another, after a suitable filling 
of the decayed cavity. 

In this place, it is proper to speak concerning the deaf and 
dumb condition, so far as it may here interest us. 

A child who is born deaf, or who becomes quite hard of 
hearing in the early years of life, does not learn to speak at all. 
Children who already speak, lose again this faculty, if they 
become deaf in early age, say somewhere up to the seventh 
year. While one ordinarily speaks only of a congenital and 
acquired deaf-muteness, it seems to me more conformable 
to facts, and important in practical relations, to distinguish 
three origins :— a congenital deaf-muteness, where the "child 
never heard and never spoke ; another which develops itself in 
a child who, answerably to his age, decidedly hears, but who 
cannot speak (an early acquired deaf-muteness) ; and a third, 
among children who have already spoken a shorter or longer 



NERVOUS EAR-ACHE. 229 

time, and then have lost hearing and speech also (a late 
acquired deaf-muteness). In a single case, it is often difficult 
to decide whether it belongs to the first or second form, for 
the information of relations, that the child has heard for 
awhile, rests frequently upon very little careful observation, 
and many parents are unwilling to have it said, that a child is 
deaf and dumb from birth. 

The pathological anatomical condition among deaf-mutes 
does not distinguish itself very essentially from that which we 
meet in individuals who are simply hard of hearing, deaf. We 
find that there appear here almost as frequently developed mor- 
bid processes in the cavities of the tympanum, as well as abnor- 
mities in the deep parts and in the labyrinth, in the acoustic 
nerve, or in the brain, especially in the region of the origin of the 
acoustic nerves in the fourth ventricle. Among the conditions 
in the labyrinth, mention has been made startlingly frequently 
of a partial and entire lack of semicircular canals. Not at all 
infrequently, the examination of the inner region of the ear 
gives an entirely negative result, so that the clear evidences of 
catarrhal irritation in the cavities of the tympanum must be 
looked upon as the essential condition ; and it appears to me 
certainly very probable that peripheric changes in the organ of 
hearing alone can bring about deaf-muteness. We leave out 
of view here, those cases of congenital imbecility, deformity of 
the brain and cretinism, where the deaf-muteness is only a par- 
tial evidence of an original, anomalous organism. 

We take a well established case. In consequence of an 
acute or chronic aural catarrh thickening of the round fenestra 
occurs, accompanied by anchylosis of the stapes. These mate- 
rial changes will be accompanied by a difficulty of hearing to a 
high degree, possibly so that a grown person will only under- 
stand when one speaks loud and long in the neighborhood of 
the ear ; this is, in the case of an adult who has formerly heard, 
and who always before has been accustomed to understand 
language, and could make it known if one did not speak 
sufficiently distinctly and near. How, now, is the same degree 
of hardness of hearing to manifest itself in a little child who 
has not yet learned to hear and to be attentive to what is to be 
heard, and to whom the words of the mother are the same ori- 
ginally that a foreign, unknown language is to us, ol which we 



230 DEAF-MUTEISM. 

know not the significance and the expression of the words % 
Such a child, who only perceives distinctly, that which those 

ind him speak, under especially favorable circumstances, 
—therefore, only at times,— to whom, therefore, the opportuni- 

\ wanting in great part, if not entirely, of gradually and by 
himself learning the meaning of the words, will soon take no 
interest in what is spoken, will cling preeminently to the mean- 
ing of signs and gestures, and will still less himself make effort 
to speak, that is to reproduce, and imitate speech, because 
the language of others, which alone gives inducement to 

ak, does not properly exist for such a child. In this 
way, hearing is less and less practised and learned. The 
child gives more and more the impression of a completely 
deaf being, with whom to speak would ', e folly. The motive 
to speak is also wanting, and thus the child, who was, properly 
speaking, only hard of hearing, grows me* ? and more deaf and 
dumb. But the same child, had he 1 , ' spoken to, as in the 
grown person, slowly and distinctly a) ' ' jar his ear, and if the 
objects designated by language had " in brought before his 
eye, would have learned gradually to hear, as also to under- 
stand what that which he heard meant ; would have taken an 
interest in language and in trying to imitate what he heard, 
that is to speak himself: by such a treatment, he would 
simply have remained hard of hearing, and would have been 
able to express himself tolerably well. So, again, if a child, 
who already speaks, becomes hard of hearing to a high degree 
at an early age. Just so in the case of a grown person, a diffi- 
culty in hearing his own voice exercises a bad influence on 
his modulation and the regulation of expression. On the 
contrary, a child who is not a ready speaker because of a diffi- 
culty of hearing those around him and his own voice, generally 
loses the capacity of distinct utterance, and gradually the power 
of language itself, unless he is compelled, with pedantic severi- 
ty, to the constant exercise of what remains of his faculty of 
hearing, and, in the case of necessity, the additional help of an 
ear-trumpet be employed, and at the same time, a methodical 
instruction introduced in distinct speaking and loud reading. 
You will now understand how we are able by means of great 
personal attention and methodical instruction in speaking and 
vocalizing to cure certain forms of deaf-muteness, or more 



DEAF-MUTEISM. 231 

correctly speaking, to prevent high degrees of hard hearing 
from developing into deaf-muteness. It is very similar with 
those methods of education which are now carried on in the 
most approved institutions for deaf-mutes, only that at a later 
period the vocal organs have lost, to a great extent, their 
capacity for modulation, and a characteristic animal howling 
appears. An entire and long-continuing deaf-muteness, to be 
sure, is considered by all men of good judgment as incurable; 
and the much boasted cures of old deaf-mutes seem to be 
founded in illusion, or in ignorance of the fact, that from the 
outset, a large portion of the deaf-mutes are not absolutely 
deaf, but are still in possession of a certain remnant of the 
faculty of hearing, on the amount of which the capability of 
further development depends. 

As a matter of course, medical treatment must be introduced 
as soon as possible, l*g*ther with systematic instruction ; and 
I could relate to you, x . i my practice, several cases in which 
deaf-muteness was ol mii sly prevented, or when in a condi- 
tion of development it *s checked, or caused to retrograde. 
For instance, there is under my treatment at present, a child 
four and a half years old, who, from the first months of his 
existence, has suffered from a discharge from both ears, and 
is conscious only of loud sounds. Until within a few months, 
when 1 saw him for the first time, he was able to produce only 
quite inarticulate barking, and other sounds which were unin- 
telligible even to the mother, so that he was already properly 
considered a deaf-mute child. Under a local treatment of the 
profuse discharge from the ear, this deaf-muteness soon de- 
creased, and with the decrease of the discharge, the child mani- 
festly commenced to notice noises which were made around 
him, and especially the words of bystanders ; as also to make 
attempts to imitate what was said. These attempts were as far 
as possible encouraged, and the child was as much as possible 
employed in speaking words and sentences. In this manner I 
succeeded not only in decreasing the degree of hardness of 
hearing, but after a few months the child possessed a tole- 
rably distinct, and at any rate quite intelligible language. 
With it, at the same time, the whole bearing of the child, who 
had been obstinate and unmanageable before, was changed : 
he became more docile, and lost something of his truly animal 



232 DEAF-MUTEISM. 

liveliness, which manifested itself in the expression of the face, 
and in the continuous squirrel-like mobility of his whole body. 
Without these local applications and the correct guiding care 
of those about him, the child would certainly soon have been 
counted among the deaf and dumb. 

You are now able to truly estimate why such great import- 
ance is to be attached to ear diseases in the first periods of 
human existence, and why, in the former Lectures, I urged on 
your consideration so earnestly, a careful investigation and 
observation of them in the case of little children ; and why, in 
consideration of its possibly great importance, I brought to 
your cognizance facts and minute details which have existed 
heretofore only anatomically, and for which the clinical esti- 
mate and decision are yet to come. 

The same affection of the ear which makes an adult only 
hard of hearing, is able to deprive the child at the same time 
of language, and causes him, during his whole future life, 
to remain in a lower state of social and mental development. 
We must not, therefore, omit, or consider trifling, what can in 
the least give an explanation of the appearance and origin 
of ear-diseases in children. 

I do not wish to say, of course, by the foregoing, that ac- 
quired deaf-muteness is always to be referred to the conse- 
quences of a high degree of hardness of hearing, and that the 
latter can always be checked or prevented by an early local 
and linguistic treatment. This may not infrequently be the 
case, but we must not forget that in the period of infancy 
as well as in old age there is a great tendency to affections of 
the brain, and especially to diseases of the cavities of the cere- 
brum and its integuments. It might be possible, also, that as 
Voltolini supposes in the case of children, there is a certain 
disposition to frequent and severe diseases of the labyrinth, and 
therefore, in childhood, a great degree of complete deafness 
develops itself proportionably more frequently than in cases of 
adults. 

Electricity in deaf-muteness in its various kinds and modes of 
application, was strongly recommended during the past century 
up to the present time, for nervous, and in fact all kinds of 
deafness. If we must be somewhat distrustful of a too general 
acceptance of a remedy, and be careful whether in these favor- 



DEAF-MUTEISM. 233 

able observations which have been communicated, the exact 
diagnosis of a competent person, or at least a somewhat thorough 
examination of the suffering parts has preceded the treatment, 
in this case, at least, we are compelled to a doubly careful 
application of this distrust, since there is generally connected 
some other application with the application of electricity, which, 
of itself, might have been able to have an improving effect on 
many forms of deafness. I mean by this the frequent filling 
of the meatus with lukewarm water. Accumulations of ear- 
wax, of epidermis and dry secretions, are not rarely at the foun- 
dation of this hardness of hearing, as we have already seen. 
They will be found, therefore, among the great masses of 
patients who have their ears electrically treated, and who 
are not examined at length beforehand. Once, a person who 
had been cured by electricity, told me quite honestly, that 
he had been surprised at the great quantity of ear-wax which, 
after a few sittings, every time after the electrical treatment, 
had secreted itself, so that his handkerchief, with which 
lie cleaned the ear, was covered with -feat brown spots. Aside 
from such cases, and also aside from cases of catarrh of the 
Eustachian tube, or of the cavities of the tympanum, which 
not seldom underlie great vacillations, in hearing, there are, 
at the same time, it is true, many improvements by electricity 
related, and from decidedly creditable persons, in eases of hard- 
of hearing which had lasted for yean, and had been treated 

and investigated sometimes by very distinguished aurists. This 

remedy must, therefore, be by no means treated contemptu- 
ously, as many aurifl it ; but we must endeavor, by 
means of these experiments, t<> get an exact knowledge oi' its 

manner of application and usefulness in many cases. The 
therapeutics of aural diseases leaves much to be desired, and 
we must always endeavor to increase the number of our 
remedies in all possible directions. A rasli denial and rejec- 
tion without thorough test is, therefore, certainly, in this case, 
appropriate. I, myself, have often made use of electri- 
city with persons hard of hearing, i. e. with inductive and 
faradaic electricity ; yet almost never alone, but generally 
after a long-continued introduction of vapors into the cavity 
of the tympanum. 
Most patients said the}- could hear better after a frequent 



234 DEAF-MUTEISM. 

application of electricity. In the case of others, improvement 
of the hearing was striking, and could be proved as well by 
speech as by the watch. 

But, in the use of my observations, I act upon the strong- 
est possible self-criticism; for very frequently, distrust and 
control must be exercised over these ear-cases ; since, it is 
proved, that the favorable influence of the vapors appears 
more after, than during the treatment, and I take for the present 
such assertions and observations of the patients with great care, 
and I do not yet attempt to prescribe in any detailed manner 
the use of electricity for the science of aural surgery. One thing, 
however, seems to me to be quite certain, since the same mani- 
festation was too frequently repeated to be merely accidental, 
and this is, that often in the case of those patients whose ears 
had been faradized for any length of time, the frequency of 
the vacillations, to which their acuteness of hearing had been 
subjected, was decreased, and the deafness and fatigue occasion- 
ed by straining to hear, was very much lessened, these phe- 
nomena having appeared before, sometimes with and some- 
times without weariness, or a desire for food. 

In faradizing the ear, one conductor, a metallic bar, insulated 
down to its point, is dipped into the meatus which is filled 
with warm water, while the other, in the form of a copper 
wire which is covered, and bare at the points, is introduced 
through the catheter some distance into the tube. If we ask 
now, which parts the electric stream will preeminently influence 
in this manner, it can scarcely be doubted that the tympanum, 
and above all the middle part of the ear, and in the latter, 
the interior muscles of the ear, viz. the tensor tympani and the 
stapedius, as also the muscles of the Eustachian canal, are 
especially under its influence. If we were able to perceive the 
pathological conditions and functional anomalies of these mus- 
cles in the living body, it is highly probable that the indica- 
tions of the applications of electricity in ear diseases could be 
formed more definitely. That muscular diseases appear also 
in the ear, is not only to be supposed a priori but we have 
an anatomical proof of it in the case of the muscles of the 
cavities of the tympanum, since I found them in my dissec- 
tions of the ear frequently diseased, in a cartilaginous, fatty, and 
granulous manner. What place must be assigned to the 



DEAF-MUTEISM. 235 

inner muscles of the ear for the physiological and pathological 
state of the sense of hearing, has by no means been exact- 
ly and definitely determined. At any rate, it will be no 
insignificant and unimportant one. Heretofore, they have 
been considered a kind of accommodating apparatus, and in 
this regard I would like to remind you, that a series of morbid 
phenomena in the eye which, heretofore, have been considered 
nervous and indefinable, now appear as lesions of accommoda- 
tion, i. e. anomalies of the accommodating muscles. It is con- 
ceivable that a similar condition may be the case in the ear, 
and especially the above-cited investigations concerning the 
influence of electricity may be explained in this manner. 

Duchesne and Erdmann 6peak, in the application of electri- 
city to the ear, of a "faradizing of the chorda tympani," 
against which it may be said that this nerve, of all others 
which here come under consideration, seems to have, at any 
rate, the very smallest importance to the ear and its functions. 

This is the place to speak of those mechanical appliances or 
contrivances for improving the condition of those who are 
extremely deaf; making the human voice and musical sounds 
more distinguishable. 

It has, hitherto, been a misfortune, that speculative mecha- 
nics have paid more attention to this subject than physiolo- 
gically educated men. The result is, that the acoustics of the 
time has famished fewer assistances to hearing than optics has 
In other words, gentlemen, we have yet to dis- 
cover spectacles for the ear. 

You would be surprised, however, at the number and vari- 
of the ear trumpets, which may be found in the possession 
of the poor patients who are hard of hearing. That which 
I have found to be the most useful for the greatest number 
of cases, consists of a stranded leather tube, of a foot or more 
in length, with horn extremities. The end inserted in the ear 
should be about the size of the meatus, the patient holding it 
in or on this part. Under certain circumstances, it will re- 
main there of itself, especially if it be somewhat angularly 
constructed. The funnel-shaped end, to be held near the 
mouth of the speaker, must be small, if it be only for conver- 
sation between two; if it be used for more persons, or for 
a considerable distance, it should be larger. 



236 DEAF-MUTEISM. 

In listening to lectures or sermons, this end should be laid 
on the table before the speaker. Such an ear-trumpet can 
he worn under the collar, in the case of men. Similar to this 
leather ear-trumpet, is one of pasteboard, which, for the sake 
of convenience, is made in sections, to be joined together 
when used. Some patients, however, are happy and con- 
tented with a cow's horn, simply adapted to the purpose. 
Apparatus of gutta percha generally deaden the tone too 
much. Those of metal are not long borne on account of their 
very strong resonance ; and so with all instruments which 
must be constantly worn in the ear, they causing too much 
irritation and exciting noises in the ear. 

The most of patients have the weakness to wish to conceal 
their infirmity, therefore they prefer such instruments as the 
small ones, which can be placed behind the ear, and under 
the hair. It is unfortunate that their value is quite as invisi- 
ble as the instruments themselves. 

The " Otaphone," from Webster, in London, has the advan- 
tage of being unseen ; and is, also, of some considerable 
service. It consists essentially of a silver clamp fitted to the 
posterior border of the auricle, which has for its object to 
cause the ear to stand farther out from the head, and thus 
to make easier the reception of sounds. For many have 
noticed very often, that many patients have a habit, when 
they wish to hear anything a little more distinctly, of laying the 
hands or fingers behind the ear, and of thus bending it forwards. 

It is astonishing what an influence this little manipulation 
has upon the hearing in some cases, and in these we may 
advise the use of the instrument. The auricle is particularly 
pressed down upon the head in the case of females, in conse- 
quence of the dressing of the hair, and the hat lying down 
upon it ; and its elevations and depressions are hardly to be 
distinguished ; for such cases, the otaphone seems to be pecu- 
liarly adapted. 



LECTURE XXIV. 

METHOD OF EXAMINING THE AMOUNT OF HEARING. 

Hearing a Watch and Understanding Conversation, as compared 
with each other. — Watching the mouth of the speaker, by a 
deaf person. — Sow a measure of the hearing power should 
be made. — Conduction of Sound through the bones. — Better 
hearing in the midst of noise. — Acuteness of hearing. 

Gentlemen — Now that we have considered all the affections 
to which the human ear is known to be liable, we have still 
to notice certain subjective symptoms, or functional dis- 
turbances of the sense of hearing ; and finally, we shall 
have some remarks to make as to the proper method of ex- 
amining patients. 

When we are dealing with that most common result of an 
affection of the ear, deafness, in order to ascertain its degree, 
we must carefully regard two things, which do not always 
stand in exact proportion to each other. First : How far the 
patient can hear ordinary conversation. Second : How far he 
can hear the sound of certain tone-giving instruments. 

We generally use a watch for the examination of the hear- 
ing distance, seeing whether the patient can hear the ticking at 
any distance from the ear ; or only when pressed close upon 
the auricle or bone. In the former case, the watch should be 
constantly held in the same direction from the ear, for instance, 
parallel with the auricle ; and instead of gradually removing 
the watch from the ear, let it gradually approach to it. Thus 
you will best guard yourself against self-deception on the part 
of the patient. Thus you will learn at what distance the 
patient begins first to appreciate the tick of the watch, and 
the one where he can distinctly count the ticks. Some aural 
surgeons hold a measure of leather between the ear and watch 
during this examination, consequently a conduction of the 



233 EXAMINING THE AMOUNT OF HEABING. 

sound occurs by means of this fixed body, and the result is 
quite different from that when the air is the only conduc- 
tor. 

We should previously have made an examination in healthy 
persons with the same watch we are using with the deaf, in 
order to determine correctly, what is the normal distance in 
which it can be heard. A watch with a clear tone, should be 
chosen, if possible. It often happens, that very intelligent 
persons are not able to distinguish between the ticking of 
the watch and the noises which they have in the ear — tinnitus 
aurium. In such cases, we would cause the patient to close 
the eyes during the examination. For certain cases, it is well 
to remember, that some watches, immediately after winding^ 
have a somewhat stronger tone, and a softer one when they 
have been cleaned by the watch-maker. Some watches have 
no tone at all, and are scarcely adapted to our purpose. For 
certain grades of deafness, we can only use repeating or 
striking watches, and these have the advantage that you can 
approach them to the ear, at one moment striking, at another 
not doing so ; and thus can be certain as to the exact truth 
of the patient's statement. 

However, setting aside all these possible ways of false con- 
clusions, the watch alone does not afford a sufficient means 
of conclusion as to the amount of hearing of the person 
examined, because the distance to which the watch can be 
heard, does not always stand in proper proportion to the 
understanding conversation. You will quite often find a case, 
where the patient is able to hear conversation of a low tone, 
quite a considerable distance, and yet can hear the watch 
only when pressed on the ear ; and then, again, you will find 
the state of things reversed, that the understanding conversa- 
tion is very difficult, while the watch can be heard when it is 
held some distance from the ear. Such a misproportion, we 
find, takes place sometimes when all the other circumstances 
which may render a correct judgment difficult, such as a pecu- 
liar mode of speech and foreign dialect, want of intelligence, 
are entirely wanting. As a general thing, persons who 
have become hard of hearing in childhood, hear the watch 
better than conversation ; and vice versa, those whose deafness 
has begun later in life, are less prevented from hearing con- 



EXAMINING THE AMOUNT OP HEARING. 239 

versation than the watch. However, exceptions occur to this, 
and perhaps we may believe that this proportion depends 
somewhat on the amount of practice in hearing a particular 
voice ; and in adults, this is naturally greater than in children. 
Yet, in some cases, we cannot thus explain this state of things, 
and you will often find that a patient hears his own voice and 
that of the surgeon, immediately after the introduction of the 
catheter, much more distinctly, while he cannot hear the watch 
any further, and possibly less. As strange as this may seem, I 
have observed it to be true in many cases, occurring in 
undoubtedly trustworthy patients, and by various experiments 
I have satisfied myself of the truth of their statements. Those 
cases which especially verify these, are those of young persons 
between the ages of seventeen and twenty ; and in cases of 
declared adhesive processes on the membrana tympani. You 
will find cases, also, where patients are deaf on both sides, and 
on one side hear the watch better, the other, the voice. 

You see, then, gentlemen, what a one-sided decision you 
will give as to the hearing of your patient, and as to the bene- 
fit of treatment, when you rely upon the watch alone for tests 
of hearing. You must then make a closer examination, by 
testing the hearing of the voice and conversation ; while one 
ear is being examined as to this, the other should be closed by 
the finger of the patient, and you should speak slowly, and 
distinctly, for instance, count, towards the side of the patient, 
varying from a loud to a soft tone, in different distances, or 
if necessary, by means of a speaking-trumpet, and cause the 
patient to repeat after you, word for word, what is said. You 
must guard against any deception, by seeing that the patient 
does not practise the habit of watching the mouth of the 
speaker. Almost all patients who are hard of hearing, very 
soon accustom themselves to watching the mouth of the 
speaker, looking always directly at it, in order to improve 
their understanding of what is said by seeing the motion 
of the lips. Most patients acquire the habit unconsciously, 
and without knowing the reason why, attempt to get opposite 
the speaker. 

Thus, you will hear as a peculiarity and a proof of nervous 
deafness, that the patients hear much worse by twilight and 
at night in bed, than when it is light about them, when it is 



240 EXAMINING THE AMOUNT OF HEARING. 

only a natural result from not having the benefit of seeing, to 
aid their hearing. 

Ladies, especially, accustom themselves to this habit of 
watching the mouth, and added to it, are such adepts in guess- 
ing, that although entirely deaf, they can hold a conversation for 
hours with their neighbor in society, without being disturbed 
from not hearing. Proper names and bearded men are an 
abomination to these ladies, for it is through them that their 
carefully concealed infirmity comes to light. 

If then, hearing the tick-tack of a watch, and understand- 
ing conversation, in many deaf persons, stand in such an open 
misproportion to each other, it has various reasons which, per- 
haps, for the greater part, rest on the. varied acoustic princi- 
ples of these processes. 

This is not the place to go very extensively into the sub- 
ject ; I will only further remark, that there is a great difference 
between hearing conversation and understanding it. A great 
many patients will tell you, that they are aware of the carrying 
on of a conversation, at a considerable distance from them, 
but it is a much less distance at which they are able to tell 
what is said. 

Moreover, the tick-tack of a watch has only one tone, or at 
the most two tones of a certain depth, which often seems to 
occur exactly in the case of deaf persons, that some tones, or 
some classes of tone, which correspond to a certain tone height, 
are entirely out of reach of the hearing, or can only be appre- 
ciated in a considerable increase in the strength of the vibra- 
tion. Thus, there are patients who hear deep tones proportion- 
ably better than high ones. Generally, however, the reverse 
is true, and tones which correspond to an excessive number 
of vibrations, in a given tone, as for example, the voices of 
females and children, are proportionately better heard, even 
when the tones are not very strong. This is, however, gene- 
rally the rule. Deep tones must be proportionately stronger 
in order to be heard equally well with high ones ; and as is 
well known, the voice of a basso must have a greater inten- 
sity, be stronger than that of the tenor, if he wishes to fill the 
opera-house as well. 

The extent of the hearing for very deep and very high 
tones may, even with normal ears, have various boundaries. 



EXAMINING THE AMOUNT OF HEARING. 241 

You only have to remember the well known fact that there 
are people who, although they have a fine and good hearing, 
can never hear the chirping of the cricket. This is said to be 
one of the highest tones that we know ; and some persons seem 
to be deaf to sounds ^bove a certain tone. 

In hearing, moreover, we are not alone concerned as to the 
intensity of the tone, and the number of vibrations in the second, 
but as to the speediness of the tones following each other, the 
space between, and a measure of the hearing, which shall 
answer all indications, must carry all these various points into 
view, in order to possess any practical value, and be also easy 
and convenient for use. 

Try, gentlemen, if you, with the aid of a mechanic, at once 
educated in physics and music, are not able to construct such 
an instrument. The acoustic apparatus now to be found in 
the cabinets, for example, the sirene, do not answer our pur- 
pose, at least so far as I have been in the position to test 
them. Perhaps such an instrument can be constructed after 
the manner of a music-box, or hand organ ; because in these 
there are a number of notes in a cylinder, of the same height 
of tone, which, by means of a simple contrivance, could be 
made to move with varied swiftness, placed with, and in va- 
rious degrees of, strength of vibration. 

As insufficient as the watch is, we have as yet no better 
measurer of hearing, only never forgetting that we must always 
examine as to the power of hearing conversation. When a 
repeating watch is not enough to show us if there is still hearing 
power, we can use a hand-bell, which may be rung behind the 
head of the patient. 

It has been often recommended to use the vibrations of a 
tuning-fork, in order to ascertain the hearing power in cases 
still further advanced, such as when the tones of a watch 
cannot be distinctly heard, as well as for other diagnostic pur- 
poses ; and we are said to draw direct conclusions, according 
as the vibrations of the tuning-fork can be heard or felt. I 
must confess, that with all my experience with this instrument, 
I cannot ascribe any diagnostic importance to the use of it ; 
and I agree fully with JRau* when he says : " The surgeon 

* Page 37 of his Text-Book. 
16 



242 EXAMINING THE AMOUNT OF HEAKING. 

canii.4 control the subjective symptoms of a patient who easily 
believes that he hears a tone, when he only feels the continued 
vibrations through the skull bones." Yery many persons are 
not in a condition, when the tuning-fork is placed on the bones 
of the head, to separate the conditions of hearing and feeling. 
This is true of even the most intelligent persons. 

From deaf-mutes and others with whom it is impossible to 
come to a previous understanding as to what you wish to learn, 
you may expect still less from the use of this instrument, as 
an aid to diagnosis. 

I have before alluded to what is called the conducting power 
of the bones of the head. We mean by this the capability 
of hearing a watch, or other tone-giving instrument, by 
placing it on one of the bones near the ear, when the audi- 
tory canal may be closed. 

Now, since the idea was had, that this capability depended 
alone upon the bones, and that the remainder of the hearing- 
apparatus, auditory canal, membrana tympani, cavity of the 
tympanum, with its contents, were entirely shut out from any 
participation in this power, it was concluded that the hearing 
or not hearing of the watch laid upon the skull, depended 
upon the integrity or morbid condition of the auditory nerve, 
and its ramifications in the labyrinth. 

The premises are not true, and therefore, all the conclusions 
are equally false. In the whole literature of this subiect 
of conducting power of the bones of the skull, a misappre- 
hension of what Johannes Muller has said, in speaking on this 
theme, lies at the basis; for this physiologist, with whose 
honored and great name, and acoustic experiments, such a 
misuse has been made in later times, especially by Erhard, 
who has already been spoken of to you as full of phantasies, 
speaks very plainly, and says, that we are not at all in 
a condition to decide how strong the conducting power of the 
bones of the head is, for we are not able to exclude the other 
parts of the auditory apparatus, in our experiments. 

I would advise you always to note in every patient, not 
only to what distance he hears the watch, from the meatus, 
but also from the mastoid process, from the temporal and 
frontal bones, and this not only in the beginning, but during 
the course of the treatment. We may be able thus to draw 



EXAMINING THE AMOUNT OF HEARING. 243 

valuable conclusions as to the diagnosis and prognosis. I will, 
however, not conceal from you, that as the result of my expe- 
rience of years in exact observations of these symptoms, I do 
not expect much to arise from this conducting power of bone, 
either in the one direction or the other. However, in a science 
where so little exact is settled upon, we should never be weary 
of assembling new facts, and here rare and unexpected mis- 
proportions show themselves, which we may not be at all 
able to explain. 

All that which Erhard, with such positiveness, has asserted 
on this subject, must be declared as purely fabulous. 

Yery often, deaf persons tell you of hearing better in the 
midst of noise and roaring sounds. Misapprehension, and lack 
of proper observation, are generally at the basis of these state- 
ments. 

When a noise takes place about us, we unconsciously raise 
our voices, so that the patient, who is less disturbed by the 
noise than we, has the benefit of this elevation of voice for 
his less susceptible ear. Many patients say they hear much 
better when riding in the cars, and the explanation of it 
must be the one given above ; moreover, the narrowness of the 
room, and the closeness of conversationists to each other. 

(I have a very distinct recollection of travelling in the cars, 
at a time when I was quite deaf, and hearing very easily what 
was said by two gentlemen sitting several seats in front of 
me, while my neighbor could not hear one word of the con- 
versation, he having healthy ears ; but as soon as the cars 
stopped, and the noise ceased, I was unable to hear my friend 
in the same seat. It is not always the case that the deaf 
hear better in the midst of noise, as I have satisfied myself 
by frequent examination as to the point.) 

Yet, there is a number of observations on this subject, which 
cannot be so summarily discussed. Thus, Willis^ in 1680, tells 
of a man who could only converse with his deaf wife when 
a servant beat a drum. This symptom received the name 
Paracusis Willisiana. Fielitz, also,* speaks of a boy, the 
son of a shoemaker, who could only hear the words spoken in 
the room when he stood near his father, who pounded sole 

* A. G. Richter's Chirurg. Bibliothek. B. is, st 3. s. 555. 



244 EXAMINING THE AMOUNT OF HEARING. 

leather on the lap-stone. When the father wished to speak 
to him, he took the hammer and pounded the leather. He 
also heard in the midst of the sound of a mill. 

These are, however, rare instances, and we may ask our- 
selves, if similar symptoms may not arise when there is a 
partial breaking off of the connection between the ossicula 
auditus, in the cavity of the tympanum, for instance, a separa- 
tion of the stapes from the incus. Heavy sounds would force 
the membrana tympani inward, and thus approximate a union 
in the severed connection of these two bones. If such a case 
occurs to you, it would, be well to try the effect of the cele- 
brated cotton wad to press upon the tympanum. 

When we speak of a morbid acuteness, or fineness of hear- 
ing, we mean an abnormal sensitiveness of the ear to all sharp, 
shrill tones and loud noises. This is present in certain irri- 
tated conditions of the brain, in the various acute and chronic 
inflammatory affections of the deeper parts of the ear, and 
then, in a sudden change from hardness of hearing of a high 
grade, to normal hearing, as for example, from removing inspis- 
sated cerumen from the ear. 



LECTURE XXV. 

Noises in the Mar or, Tinnitus Aurium. — Examination of 
Patients. — Conclusion. 

Gentlemen — We must, to-day, devote a little time to the irri- 
tated condition of the auditory nerve, manifesting itself by 
noises in the ear — Tinnitus aurium. The causes for this sensi- 
tive condition of the nerve, which does not depend on its irri- 
tation from external impression, may lie in the nervous parts 
of the ear, and exist in any of its morbid conditions ; for 
we have seen that tinnitus aurium has been a symptom in 
the most of the diseases of the ear, which we have studied 
together. Every irritation, from any direction, working upon 
the acoustic nerve, will declare itself by its own peculiar 
symptoms. 

"We find these subjective tones, or noises, in all irritated, 
abnormal conditions of the brain, whether arising from the organ 
itself, or arising as a reflected sensation or irritation from any 
source whatever. We need not speak of the peculiar affec- 
tions of the cerebrum, such as intoxication, anomalies of the 
materials of the blood, transient and permanent interferences 
with free circulation, with also that class of indefinable morbid 
symptoms, to which the vague names, relaxation of the nerves, 
excessive nervous irritation, nervousness, and the like, are 
attached. 

Generally, these noises in the ear depend on abnormal con- 
ditions in that organ itself. We find tinnitus always present 
in acute inflammation of the membrana tympani, and of the 
cavity of the tympanum ; and furthermore, it is present in 
coincidence with, or, as a result of all causes, which increase 
the pressure on the fluid of the labyrinth ; if, for instance, the 
membrana tympani is pressed inwards by inspissated cerumen 
resting on its surface ; or, if the Eustachian tube is obstructed 
so that the membrana tympani and the ossicula auditus lie 



24(5 NOISES IN THE EAR. 

deeper inwards ; or, if the stapes with its membrane, or the 
membrane of the fenestra rotunda, from any cause, be pressed 
against the labyrinth. 

Every thickening and rigidity of the membranes of the 
fenestras, if an increased tension be connected with it, may 
alone excite a very oppressive noise in the ears or head ; and 
as chronic catarrh is the most common cause of deafness, so 
tinnitus aurium appears oftenest to result from the same cause. 
Chronic hyperemia of the ear will often, also, produce this 
disturbing symptom ; but we often see a considerable develop- 
ment of vessels on the membrana tympani without any com- 
plaint from noises in the ear. When ear patients, with good 
hearing, and negative symptoms in the ear, complain of noises 
in the ear, never omit to examine carefully the mucous mem- 
brane of the pharynx, because such irritative symptoms often 
arise from a morbid condition of this part. 

Fleischmann, the Erlangen anatomist, relates a case where a 
man complained for years of a very annoying noise in the left 
ear, and in the post mortem section, a small grain of barley was 
found, which lay between the pharyngeal entrance of the tube 
and the bony part of the Eustachian trumpet.* More often 
the patients are not able to select one ear as the situation 
of the noise, but express themselves undecidedly, or say, that 
the noise is not so much in the ear as in the head. 

(I have a case now under my observation where, in conse- 
quence of blows on the head, the membrana tympani was rup- 
tured, and the continuity of the little bones severed, a high 
degree of deafness resulting, and very annoying tinnitus auri- 
um ; all the other active inflammatory symptoms having sub- 
sided. The other ear is in a normal condition^ and all the 
noise is referred distinctly to one ear.) 

Not to speak further of these subjective noises in the ear, 
which arise as symptoms of irritation of the auditory nerve, 
there are sounds comprehended under the name, noises in the 
ear, which have for their cause real sounds producing vibra- 
tions which are excited in the system itself. These are the 
sounds described as pulsating, intermittent sounds, which, for 
the greater part, are nothing more than the pulsations of arte- 

* Iinke'a Sammlimg. I. Heft., & 18S-. 



NOISES IN THE EAR. 247 

rial vessels, be they in the internal carotid which runs through 
the temporal bone in manifold meanderings, or in the smaller 
arteries. We may excite transient, but decided arterial pulsa- 
tion in the ear, by sudden movements of the head. 

Bayer* relates a case of pulsating sound in the head, 
synchronous with the pulsations of the heart, which was mani- 
fest on auscultation, and which immediately ceased on pres- 
sure of the mastoid branch of the posterior auricular artery. 

No peculiar aneurismal widening of the vessels could be 
found, or any insufficiency of the valves of the heart, or mor- 
bid tone in the aorta or carotids, so that this noise must have 
had its origin in some especial peculiarity of the branches 
of the arteries behind the ear, or in some change in the* parts 
over which they passed. Bayer advises auscultation in all 
noises in the ear, so that one may see if the physician, as well 
as patient, may not be able to detect the sound. 

Since in many rodentia or gnawing animals, as for instance, 
the rat, mouse, squirrel, etc., the internal carotid passes through 
the side of the stapes ; so in man, according to Hyrtl,f there 
is always a capillary arterial branch between the side of the 
stapes through to the promontory, and exceptionally, there is 
a larger artery running through the stapes. 

"When the last-named state of things exists, it seems to me 
scarcely questionable, that intermittent noises in the ear 
depend on this communicated motion of the stapes, to which 
the patient may accustom himself, as the miller to the noise 
of his mill. 

Certain blowing and whistling sounds occurring in chlorotic 
and anaemic patients may be referred to the vessels of the 
petrous portion of the temporal bone, and I call to your mind 
that the internal jugular vein, and with a constant enlargement, 
its bulbus, lies immediately under the floor of the cavity of the 
tympanum. 

I do not know any special treatment of tinnitus aurium ; we 
must always attack the cause of the symptom. As we have 
said, very often these subjective symptoms are caused by abnor- 

* Comptes rendus des Seances et Memoires de la Societe de Biologie. Ann6e 
1854. P. 169. 

\ Yergleichend-anatom. Untersuchungen uber das innere Gehororgan des Men- 
schen und der Saugethiere. Prag : 1854. S. 40. 



NOISES IN THE EAE. 

ma] pressure, which morbid conditions on the fenestra rotunda 
and oyalifl have caused to be exerted on the fluid of the laby- 
rinth. This explains why frequent air-baths, or douches, often 
effect BO much, when given for chronic catarrh, for noises in the 
oar, oven when no improvement in the hearing results. Some- 
times the mingling of a few drops of chloroform to the vapor 
of warm water does good, and we can also employ chloroform 
and olive oil as a counter-irritant. 

Now, gentlemen, in closing our meetings together I would 
urge upon you a diligent and careful recording of your cases- 
A comprehensive history of an observed case carried on through 
the treatment to discharge, or to an examination of the dead 
body; is the best means of making a young man an intelligent, 
carefully observing, sound reasoning physician. 

Such an objective series of observations is of uncommon 
value, in that it always forces us to a constant reason or basis 
for our opinions, and bears in itself the necessity for severe self- 
criticism. 

The more exact and objective are a physician's histories of 
cases, the more is he in a condition to advance the interests of 
science, and to assist suffering humanity. The less he does 
this, and the quicker he is to draw his final conclusions and 
diagnosis, the quicker and more certainly he falls into the 
beaten track of a mechanic, and so common and convenient 
self-complacency of many old practitioners to an unscientific 
and purely symptomatic estimation of disease. 

It is not necessary to tell you how indispensable, full and 
careful histories are for observations, which may extend through 
years, and for the explanation of post-mortem appearances. 
Nowhere is a thorough and purely objective observation of 
cases more necessary than in a branch of medical science, such 
as aural surgery, which is so incomplete, and we may say one 
which until lately has been very carelessly investigated. 

Every honest logical observer is here a gain for science, be- 
cause he collects new facts, which may serve as proofs for those 
already furnished, and render our knowledge more and more 
complete. It is not enough to make a few scanty notes, and at 
the close the preconceived diagnosis, but you must give all 
the details that the nature of the case demands, strictly follow- 
ing it with no external prejudice. This is generally best at- 



NOISES EST THE EAE. - 249 

tained by a certain prepared general plan, perhaps such as 
I now give you : 

Name, age, profession or occupation, residence, origin and 
course of the disease. (Observe if accompanied by pain, 
noises in the ear, if any exciting cause existed, and of what 
nature. If deafness resulted immediately, or some time later, 
when the present condition of the hearing commenced, if this 
be constant or variable, what other symptoms of disease were 
present.) 

Present condition, subjective. Hearing distance with watch 
and voice, conducting power of bones of the head, patient's 
own voice clear or muffled, worse in morning or evening ? 

Is voice or conversation of patient peculiar ? 

"When and under what circumstances do deafness and noises 
in the head increase ? 

Objective. — State of external canal, or meatus, cerumen, 
membrana tympani, brilliancy, light-point, color, handle of 
the malleus. Membrane of the pharynx, catheterization and 
air-bath or douche. Changes in hearing distance occurring 
alter this, or on membrana tympani. General condition, head- 
ache, vertigo, hereditary predisposition. 

Treatment previously pursued. 

Treatment. — Diagnosis. — You see, how many things are to 
be noticed in our first examination of a patient, and that it 
will occupy much time. You must never allow the opinion or 
judgment of the patient to overcome your own. He is apt to 
underrate important facts. You ask the questions, and the 
patient has only to answer, but you will be often obliged to 
remind the patient of your question. It is incredible how 
much labor it sometimes costs to get a direct answer to a ques- 
tion, and especially as to the beginning of a complaint. A 
patient who has been hard of hearing for years, after he has 
excused himself many times, will tell you, that he has been deaf 
for six weeks. After the patient has stated when his com- 
plaint began, ask, if before that time he had perfectly good 
hearing in both ears, and you will be surprised to find how far 
back the period will be pushed. You will find similar incon- 
sistencies in other patients, so that you must never come too 
quickly to decisions. 

Gentlemen — In the beginning of our study together we 



250 NOISES IN THE EAR. 

could find no good reason, why so few physicians interest 
themselves in the cure of the diseases of the ear, and why the 
interest in this field of our science was so little. 

Now, perhaps, you may inquire, if it be not that the exami- 
nation and treatment take so much care and time. 

Diseases of the ear, in consequence of their slow, and often 
painless course, come very late to the attention of the physi- 
cian, at a time when very little can be expected for a rapid 
and certain cure. This is undoubtedly now true, but you 
must remember, that quite another condition of things will 
occur so soon as the public learns that with ear-diseases as well 
as other complaints much may be easily done in the begin- 
ning, but that the older the case, the more unfavorable the pro- 
gnosis, and as soon as it is learned that physicians may be found 
who will undertake their treatment. As to the trouble and 
painstaking required, it is not to be denied that a physician 
of the present time, who labors not only for practice, but also 
for science, must have a wonderful amount of patience, endur- 
ance, and perseverance, and it may be owing to this fact that 
surgeons, who as young men commence the aural practice 
with great zeal, as rarely continue in it. However, in Ger- 
many especially, it will be a long time before convenience 
takes the precedence of duty and right, and such reasons for 
abandoning, or not taking up the practice, can never be gene- 
ral. Furthermore, we will not forget that the beginning of 
everything is hard, and that the study of aural surgery is still 
in its infancy, and as it progresses, its scientific and practical 
study will be easier and simpler, and thus, gentlemen, we come 
back to that which we observed in our first coming together. 
The lack of interest in aural surgery is a wrong state of things 
founded on ignorance and prejudice. 

May it have been my fortune, in the course of our mutual 
studies, to have fully proved the incorrectness of the general 
acceptation, and I would that I may have excited such a pecu- 
liar interest in this part of medical science, that you will 
always willingly and with success undertake the treatment of 
the deaf, and may I have caused some of you to labor specially 
and only in this department. 



INDEX 



Abscesses in brain, resulting from otitis, 200. 

Agnew, Dr. C. R, removal of sequestrum from ear, 210. 

Air bath, or douche, action of, 94, 97. 

American Medical Times, case from, 49. 

Amount of hearing, examination of, 238. 

Artillerists, injury to membrana tympani, 82. 

Artery, auriculo-profunda, 57 ; posterior auricular, 48 ; pulsating sounds of, 
in ear, 247. 

Arcularius, 48. 

Aristotle, 20. 

Autenrieth, proposed artificial drum, 185. 

Auditory canal, external, anatomy of, 21, 34; narrowing of, 74; examina- 
tion of, 27 ; dryness of, 35. 

Auscultation of ear, 92. 

Auricle, diseases of, 25. 

Bell, Benjamin, 87. 

Brain, connection of ear with, 200. 

Bougies, use of, through Eustachian catheter, 150. 

Bibbins, Dr., case of cerebral abscess from otitis, 201. 

Cataplasms, on use of, 48, 72. 

Caries of temporal bone, 194, 199. » 

Caustic holder, 195. 

Calcareous formations on membrana tympani, 117, 145. 

Catarrh, definition, of, 61, 104 ; purulent, in children, 167. 

Cerumen, diminished secretion of, 34 ; inspissated, 37. 

Chorda tympani, faradization of, 235. 

Cleland, Archibald, on illuminating ear, 30, 85. 

Clark, Dr. Edward, on perforation of membrana tympani, 164. 

Cicatrices on membrana tympani, 184.. 

Cotton, stuffing ear with, 63. 

Czermak, on laryngoscopy, 129. 

Dentition, difficult, 178. 



INDEX. 

DeaAnuteism, 230. 

Diploo, connection of vessels of with endo-cranium, 196. 

DiefFenbach, on deafness with cleft palate, 127. 

Ear trumpets, 236. 

Electricity in nervous deafness, 231, 233, 240. 

Erhard, Dr. Julius, pressure on membrana tympani, 187; criticism on, 227. 

Emetics in aural catarrh, 110. 

Eustachian tube, lining of, 21 ; catheter, 86. 

Eustachio, Bartholmei, 85. 

Exostoses in auditory canal, 75. 

Examination of patients, mode of, 249. 

Eye Infirmary, N.Y., cases of otorrhcea in, 195. 

Facial paralysis, 209. 
Fabrizius von Hilden, 33. 
Fenestra ovalis and rotunda, 118. 
Forceps, angular, 32. 
Foreign bodies in ear, 45. 
Fossa sigmoidea, 69. 
Fossa, Rosenmuller's, 131. 
Furuncle in auditory canal, 52. 

Gargling, proper method of, 152. 

Granulations, comprehended in term polypi, 191. 

Guyot first introduced Eustachian catheter, 85. 

Hairs obstructing view of auditory canal, 27. 

Hoffman, Dr., perforated mirror, 28. 

Holcomb, Dr. W. H., modification of nozzle of syringe, 44. 

Illumination of ear, 31. 

Itard, ear speculum, 28, 203. 

Kramer, Dr. Wilhelm, local character of aural diseases, 81 ; pn nervous deaf- 
ness, 218 ; speculum of, 28 ; on inflammation of periosteum and cutis, 
61. 

Laryngoscope, 31. 

Labyrinth, structure of, 21. 

Lebert, on pyaemic symptoms in otitis, 198L 

Lushka on polypi in antrum, 136. 

Light, coniform point of, on drum, 107. 

Malleus, fracture of, 83. 

Meissner on diseases of children, 172. 

Malgaigne, 62. 



INDEX. 253 

Mastoid process, perforation of, 213. 

Membrana tympani, examination of, 29 ; structure of, 21 ; paracentesis of, 
165 ; artificial, 185. 

Meniere, cases from, 189, 209; on nervous deafness, 223; necrosis of audi- 
tory canal, 195. 

Muller, Johannes, on mucous membrane, 126 ; false conclusions from doc- 
trines of, 242. 

Mercury in chronic myringitis, 81. 

Muscles, stapedius and tensor tympani, 109 ; inserted into Eustachian iube, 
126. 

Myringitis, 77. 

Nasal catarrh, treatment of, 156. 
Nervous deafness, 217. 
Necrosis of middle ear, 210. 
Noises in ear, 246. 
Nomenclature, the author's, 60. 
Noyes, Dr. Henry D., case from, 188. 

Oils, dropping in ear, 71. 

Otoscope, 93. 

Otitis externa, 61 ; interna, 158 et seq. 

Otorrhcea, only a symptom, 195; treatment of, 209; prejudices against 

treatment, 213. 
Otalgia, 228. 
Otaphone, 236. 

• 
Perforation of membrana tympani, 180. 
Politzer, Dr., of Vienna, 96. 
Poultices cause otorrhcea, 81. 
Palate, muscles of, 126. 
Pharynx, catarrh of, 124, 133. 
Polypi, origin of, 191, 194. 
Post, Professor A. C, cases from, 56, 212. 
Periostitis, post-aural, 212. 
Paralysis, facial, 205. 
Probing ear, 83. 
Pyaemia confounded with otitis, 197. 

Rhinoscopy, 129. 

Rau, on sounds dipped in argent, nitrat, 151 ; on objections to Eustachian 

catheter, 99 ; other subjects, 47, 48. 
Rayer, on communicated sounds in ear, 247. 

Simrock, Dr. J., on pharyngoscopy, 130. 

Streckeisen, Prof, case from, 169. 

Schwartze, Dr. H., diseases of ear in typhus fever, 162, 171. 



254 INDEX. 

Seanzoni, Prof, on transient deafness, 220. 

Semeleder, his illuminating spectacles, 130; on polypi, 132. 

Sputa, 132. 

Syringe, ear, 14. 

Syringing, method of, 45. 

Thickening of drum, 81. 

Thomas, Dr. T. Gr., case of cerebral abscess, 201. 

Tonsils, hypertrophy of, 126. 

Toynbee, determining permeability of Eustachian tube, 96 ; post mortem 

sections of ear, 219; artificial membrana tympani, 185; clinic, 13; 

speculum, 32 ; on inspissated cerumen, 41 ; on exostoses, 75. 
Turnbull, of London, 90. 
Tumors, pearl-like, 217. 
Tuberculosis of temporal bone, 204. 
Typhus fever, 198. 

Yalsalvian experiment, 95. 

Vertigo a symptom of nervous deafness, 225. 

Verduc, baiting insects in ear, 47. 

Virchow, report of, on Eustachian catheter, 158. 

Virchow, 198. 

Voltolini, post-mortem sections of internal ear, 219. 

Wagner, Rudolph, central organ of hearing, 219. 

Wilde, of Dublin, clinic, 18; speculum, 29; aural surgery, 46; collapsed 
membrana tympani, 142 ; polypus snare, 192 ; case from, 82 ; on exos- 
tosis, 75 ; on otorrhcea, 208. 



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